62677D - Oryszak

1CAMA / [-'DREDGE & FILL �� 621
;ENERAL PERMIT Previous permit#
1New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
•ized by the State of North Carolina, Department of Environment and Natural Resources
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
IXRu)es attached.
Name A Project Location: County P+"Vr\ "0(,
Street Address/ State Road/ Lot #(�) i
��f State ZIP i Y Kc`:
F # (> Subdivision
ed Agent (1 04 City,,;` ZIP (P L
❑ CW "'�4 EW EyOTA ❑ ES © PTS Phone # River•BasinU
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
Adj. Wtr. Body l) v
❑ PWS: ❑ FC: A _
yes / no PNA yes /�nol Crit.Hab. yes ti °� Closest Maj. Wtr. Body
Project/ Activity l,j . k `', i 1 i-r Loj l . u ► l � iin111 A i3
ck) length
1(s)
ngth
tuber
d/ Riprap length
g distance offshore
ix distance offshore
-iannel
bic yards
np
ise/ Boadift j X
ll/ul''ldozing
�T * It, /
e Length
not sure yes no
s: not sure yes no
ium: n/a yes no
{ yes no
P
ed: yes no
rmit may be required by:
- - - -- - 11 It
(Scale: ' J!
i
t�UY1� Y,/ j 04 �U-A A�L' ❑ See note on back regarding River Basin i
17rj. /)..1 Ali tUAV j,r- i G" 1, n:. A LiAI -i i il>'fA,tA+,..1

NC Division of Coastal Mgt, Habitat impact Computer Sheet
Applicant: 61%
1.1tl_ Permit #:
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measuremei
found in your Habitat code sheet.
Habitat Name
U3Dredge
TOTAL Sq. Ft.
(Applied for.
DISTURB TYPE Disturbance total
Choose One includes any
anticipated
restoration or
temp impacts)
❑ Fill ❑ Both ❑ Other 5 O
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
( S c'
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated fin
disturbance.
Excludes any
restoration and
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other
g
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 ❑

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12-19 13:56 USRTPLN8 919-543-2552 >> 919107548049
MCDEWR
North Carolina Department of Environment and Natural Resources
_pivisiPat McCrory U11V 0astal"Managerient
Governor Braxton C. Davis
Director
AGE UT AQTH_6F2lZAT10N FQkff-
Date- _1kA))3
Name of Property Owner Applying for Permit -
Owner's Malling Address ,
Phone Number CqLh..?,Y(- ViY
John E. Skvarla, III
Secretary
Name of Authorized Agent for this project:
Agent's Mailing Address,.
2�-d �246 �_-
Phone NumberOtl 0)
.3
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install of construct the following (activity):
For my property located at P 76
-3 Vow)
This certification,iav .-thru (dato)
rope -dwn .nature op ate
i-i"X=iVED
DCM WILMINGTON, N(

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Clifford Orvszak
(Name of Property Owner)
property located at 3576 Van Buren Street Su --ply North Carolina 28462'Lot3
(Lot, Block, Road, etc.)
on Shallotte River in Brunswick County , North Carolina.
(waterbody) (Town and/or County)
Agent Name Christopher D. Stanley Agent Phone [phone]
I certify that I own property adjacent to the above reference property. The individual ap1 m for
this permit has described to me as shown below, the development he is proposing at that location,
and, /
1/ I have objections to this proposal.
I do not have objections to this proposal.
WAIVER SECTION
I understand that a pier/mooring pilings/boatlift/boathouse must be set back a minimum distance
of fifteen (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% I do not wish to waive
I do wish to waive that setback requirement
---------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development)
(Applicant Information)
136 Station Drive
Mailing Address
Morrisville NC 27560
See Attached Drawing
(Riparian Property Owner Information)
Signa
_Jam F. Roaers

__ _
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customer requests Waivers Insurance Is void Federal ggenc I wish delivery tp be of signature.
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� -� ��
Tracking Number: E1522059077US
Scheduled Delivery Date: January 17, 2014, 3:00
pm
Money Back Guarantee
Signed for By: WAIVED !i SAINT JAMES, NY 11780 /i
1:18 pm
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DATE & TIME STATUS OF ITEM
LOCATION
January 17, 2014, 1:18
pm Delivered
SAINT JAMES, NY 11780
January 17, 2014 , 11:14
am Arrival at Post Office
SAINT JAMES, NY 11780
January 17, 2014 , 7:41 Processed through
am USPS Sort Facility
MELVILLE, NY 11747
January 17, 2014 , 6:55 Processed through
am USPS Sort Facility
JAMAICA, NY 11430
January 15, 2014 Depart USPS Sort
Facility
FAYETTEMLLE, NC 28302
January 15, 2014 , 7:31 Processed at USPS
PIT) Origin Sort Facility
FAYETTEVILLE, NC 28302
January 15, 2014 , 4:34 Dispatched to Sort
pm Facility
SHALLOTTE, NC 28470
January 15, 2014 , 2:59
pm Acceptance
SHALLOTTE, NC 28470
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What's our tracking (or receipt) g number? WILMINGTON, NC
p )
Ttack It JAN 2 8 2014

UNI TED STATES
I'OST/�L SERVICE
Date: January 22, 2014
Sabrina Babson:
The following is in response to your January 16, 2014 request for delivery information on
your Priority Mail Express® item number E1522059077US. The delivery record shows
that this item was delivered on January 17, 2014 at 1:18 pm in SAINT JAMES, NY
11780. The recipient's signature is not available because the waiver of signature that
you authorized was exercised at the time of delivery.
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Sincerely,
United States Postal Service
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DCM RECEIVED
N
,NC
JAN282014
[R-7
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/1,2-3-11