61613D - Sears

❑CAMA / ❑ DREDGE & FILL
GENERAL PERMIT
Previous permit#
New ❑Modification ❑Com fete Reissue ❑Partial Reissue
P
Date previous permit issued
P
prized by the State of North Carolina, Department of Environment and Natural Resources tt ii ,,
Coastal Resources Commission in an area of environmental concern pursuant to 1 SA NCAC �T H Lit
Rules attached.
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ntName
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Project Location: County ,u � ' t l L1
r
s l.Ii, 990, A �rs-lyo iV�e-
Street Address/ State Road/ Lot #(s)
bY- Viarrt StateKL ZIP -4-4`1i2-- 1-�'
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-5 Fax # ( )
Subdivision
zed Agent fi,����t
f LA.iet�r�:,
Ci(((11A
kLc 1'fACJ% ZIP
❑ CW [�EW VZ PTA ❑ ES ❑ PTS
Phone # River Basin
'
❑ OEA ❑ HHF ❑ IH UBA 7-N/A
1
Adj. Wtr. Body 4& OJ (nat
❑ PWS: ❑FC:
yes / no PNA yes /(no Crit.Hab. yes / no
_.
Closest Maj. Wtr. Body
if Project/ Activity
ock) length
ength
umber
■■■■Y■tea■■■
ad/ Riprap length
■■■�■■1.1�>u�■
ig distance offshore
iax distance offshore
ENIPW11MEMO
jbic yards
imp
use/ Boatlift
Bulldozin
K.
■■■■
ne Length
not sure
yes
j no
gs: not sure
yes
no ~
mum: ,,n/a
. -yes
no
Attached:
r
/+ es
no
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xo
(Scale:
ling permit may be required by: !/1�j oik I Kw(I L.I,ti ❑ See note on back regarding River Basin
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NCDENR
North Carolina Department of Environment and
Division of Coastal Management
Orly Eaves Perdue Braxton C. Davis
Dmor Director
Natural Resources
Dee Freer
Secre
AGENT AUTHORIZATION FORM
Date: 3
of Property Owner Applying for Permit: Name of Authori ed Age t for this project:
is Mailing Address:
3i S. Cad r, vim.
r . 6L - 7-n 71 k?'i-%3 IP
Number Akci �1�— Oq\3
Agent's Mailing Address:
3313 2t'crn n. ��a . C1vJ
ZZUCA
Phone Number Alb) 2-VA. --JU50
y that I have authorized the agent listed above to act on my behalf, for the purpose of applying
J obtaining all CAMA Permits necessz
% 1 • / _I
y property located at
Drtification is valid thru (date)
to install or construct the followin, (activity):
LVr,�,coo tnr�A k A v kv)
a D l
Pocilewy Owner Signature Date

US MAIL
CERTIFIED MAIL — RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner: 5 --- — - --
Address of Property:
(Lot or Street #, Stree or Road, City & County)
Applicant's phone ti: %C 9j 21�°► Mailing Address: ��[� rt1SC11
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this pern
has described to me as shown on the attached drawing the development they are proposing. A description of drawin
with dimensions, must be provided with this letter.
`Ihave 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 E.
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, or lift must be set back a minimum distance
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(;d'" I do wish to waive the 15' set back requirement.
I do not wish to waive the 15' set back requirement.
(I'Vopero Pwner In
Print or Type Name •
P—
A11 1.1.7 ........
Signature (�
Print or Type Name
Mailing Address
r Information)

HAND DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFT/BOAATHOUSE)
I hereby certify that I own property adjacent to A -I 1A��Jl„(�„f s s
(Name of Property Owner)
property located at
on
(Waterbody)
(Lot, Block, Road, etc.)
in
(Town an or Coun )
Applicant's phone 44%COA\(�-!MGMailing Address: ZU-36 .7• G,'S&DR !�Wt--
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (I T) 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 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)
-V��a.rz. A-)rc, roc c
(4'%1 k L; ) V-Osn-g W CL VV-\-0
--------------------------------------------------------
(Information for Property Owner Applying
for Permit)
Mailing Address
(Riparian Property Owner Information)
Signature
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(Domestic IInsuranceCoverageProvided)
M1
For delivery information visit
our website at
www.usps.connu
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Postage
$
.10 . 4b
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f�
Certified Fee
$3.10
lit
t
0
Return Receipt Fee
$0.00
Postmark
Here
O
(Endorsement Required)
M
Restricted Delivery Fee
(Endorsement Required)
O
117
Total Postage & Fees
Is
$3.5b
05/03/2013
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m
Sent To
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treat, pt. o.;
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or PO Box No.
P-
------ --- ---------------------------------------------------------------------
State, ZIP+4
PS Form 3800, August 2006
See Reverse for Instructio
n
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i

applicant:
We:
Permit #: Ll ` Lt is D
escribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
fund in your Habitat code sheet.
abitat 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/or
temp impact
amount)
(_ Dredge ❑ Fill ❑ Both ❑ Other
p�5
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
p0rma +�
1
'ba b
�
NI
4or RESOURCES.
ONE 50URCE. INFINITE
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 ❑