63145D - Kluck

A'16
CAMA / VADREDGE & FILL R1 K
IENERAL PERMIT/'
flew ❑Modification []Complete Reissue El Partial Reissue
Previous permit #
Date previous permit issued
63
ized by the State of North Carolina, Department of Environment and Natural Resources -7 ++
oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC 1 l 1nn
, 7 } . ��Q
I ❑ Rules attached.
Name Project Location: County U NJ 54 IC4d-
L `J O110 1✓z;-r I Street Address/ State Road/ Lot #(s)
a4l(N 9, State NC ZIP 2�� 7 �w 29" Sr•
0 to) U* � � Fax # ( )�� t C11S�v'C (S*ivision
;d Agent CV �I cityI< < ZIP
cw DEW E54TA ids ❑ PTS Phone # ( ) River Basin
❑ OEA CI HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body I S C HJ Xnn /n
F PWS: ❑FC: `T
,es / Fo PNA /� Crit.Hab. yes / no Closest Maj. Wtr. Body A Mll
Project/ Activity P (� 11/ J I E-Y 6 & � L&2S2
_ (Scale:
k) length
ar(s)
gth
fiber
Rtanc length
distance offshore
: distance offshore
c yards
e/ Boatlift
Ildozing
�5ac��
Length 1 f
not sure yes
;i
not sure yes n
im: n/a yes �Q
tached:
g permi

INTERNATIONAL MONEY ORDER Z.
MoneyGram.
To Validate: Touch the stop sign,
then watch it fade and reappear
PAY TO THE
ORDER OF:/
P GAR A LA A
ORDEN DE: L)
IM 0 Nt - SEETACK BEFORE CASqING
LU
BN
ORION, 0-
PURCHASER, SIGNER FOR DRAWER COMPPADOR, FIRMA DEL LIBRADOR
PURCHASER, BY SIGNING YOU AGREE TO THE SERVICE CHARGE AND OTHER TERMS ON THE REVERSE SIDE
ADDRESS:/
DIRKWN:
Payable Through ISSUER/DRAWER:
Wells ult, Fargo Bank, N.A.
FaribaMN MONEYGRAM PAYMENT SYSTEMS, INC
19 1900 S 3 31: S90 9 7 ?0 SL2130i'm 90 C,(? j,3kJ45 �q,
INTERNATIONAL MONEY ORDER
MoneyGram.
To Validate: Touch the stop sign,
,, then watch it fade and reappear
4
MoneyGrary
KEEP A COPY OF THIS STUI
FOR YOUR RECORDS/
MANTENCA UNA COPIA DI
ESTE RECIBO PARA SUS ARCHI
73
MoneyGrarr
19
co
C:)
Co

Division of Coastal Mgt. Habitat Impact Computer Sheet
;ant: C tf7Z t STbe*--YZ gLV C lL
2,I �/I j
Permit #: & � 14-S
'ibe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
i in your Habitat code sheet.
at Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/oi
temp impact
amount
�vl
Dredge ❑ Fill El Both ElOther _�✓/
I
�j C-)2
3 C 2—
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date (gcP 1s , ?_0
Name of Property Owner Applying for Permit:
0,HielS-r6P l`;r-72. KL-U
Mailing Address:
LELf1noQ ; &jCG Zcz�4 5-1
I certify that I have authorized (agent) 13R hi N O d l J & P I M 6,5 to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
10 -7 S vl) '7, q rrf 15,1-
This certification is valid thru (date) 0 C -r :3 1 J 2 CS, 13
Property Owner Signature Date

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
,'4K I5LAI�D
Address of Property:
s C}
(Lot or Street #, Street or Road, City & County)
Applicant phone #: Cl d 3 0 � _ a 5-& � Mailing Address'
135,39 o � � ro
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are oposing. A description or drawing with dimensions must be provided with this letter.
theyare
have no objections to this proposal I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at www.nccoastaimangement.net/contact dcm.htin or by calling 1-888-4RCOAST. No
Les once is considered the same as no objection if you have been notified by Certified Mali.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a
minimum distance of 15' from my area of riparian access unless waived by me. (if you wish to
waive the setback, you must initial the appropriate blank below.)
9�z I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
new nformation)
Signature
CMlo ►5-+roPjfi-r:?e— KLW C4L
Pnnt or Type Name
S -3 9 0 `p r—o P—EST D�
Mailing Address
et- l/�►" /J Ili L
City/State2ip
nin-.3G�`�'3�
Telephone Number
Sep 11;
Date
(R/�ipparian Property
ILL'—"J
C 4i-Z1--!1 -6Q`P Ls'o �
Print or Type Name L
Z�T 3i
Mailing Address
City/statelzip
Telephone Number
l -- C j- ? i - ---
Date

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
f �o
(Lot or Street #, Street or Road, City & County)
Agent's Name #: lt,4'Ydl - 3,fz
Agent's phone #:
'� / V [ 4
Mailing Address: r Ol� /arc
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
10— I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15' from my area of riparian access unless waived by me. (If you
wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
Print or Type Name
(Adjacent Property
roprty Ownformation)
Signature
edw�,-..j JvN�S
Print or Type Name

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