62627D - Smith

M 626
:.AMA / ❑ DREDGE & FILL 1 D 1
iEN ERAL PERMIT v Previous permit #
qew [-]Modification❑Complete Reissue ❑Partial Reissue Date previous permit issued
ted by the State of North Carolina, Department of Environment and Natural Resources r
>astal Resources Commission in an area of environmental concern pursuant to 15A NCAC J ( Rules attached.
ame
Yk ` `} Project Location: County � t�`'
Street Address/ State Road/ Lot #(s)
-� (�
�(! �� State ZIP ````
Fax # () Subdivision Iv
sd Agent City ZIP
C l� pti�
❑ CW ftW /C',PTA Li ES ElPTS Phone # ( ���(h tRiver Basin
❑OEA ii❑�rHHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body 1,ti7v�lliJ� ,`' \✓'' \ (natt,/n
❑ pI�[S: ❑ FC: w Vt
Closest Mai. Wtr. Body
no
PNA y / no) Crit.Hab. yes,/ no
Project/ Activity _
:k) length
(s)
er(s) X x
ngth
-nber
I/ Riprap length
distance offshore
uc distance offshore
cannel
bic yards
np
ise/ Boatlift
iulldozing
i
ie Length
not sure yes no 4-
gs: not sure yes no `
iriuma n/a yes., no
y t ``
. g1 Y no
Attached: yes �'�,C( I
ling permit may be required by:
311
(Scale:
❑ See note on ack regarding River Basin
!'7A Lf rk A A f ild.- v i

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
McCrory, Braxton C. Davis
>vernor Director
:MORANDUM
To: Melissa Sabastian
From: Shaun Simpson
Date: October 4, 2013
Subject: Check refund for GP62627D
r Melissa:
•equested by Debbie Wilson, please refund $200.00 to the below named person.
project was noncompliant with local building code regulations.
ached is a copy of the check.
:ck Number: 002062
>osit Number: 133047
)osit Date: 10-3-13
ase make the check payable to: Richard I Smith
Send to: Richard J. Smith
90 Fairmont Street
Ocean Isle Beach, NC 28469
� on file w/Melissa S.
John E. Skvarla, I
Secretary

-- 002062
10
5445
-Date
n $'0D,.,
Dollars
,mac,
NP
4880 2 5 7 7 L 6 420 6 2
/z 1211►(�Lq-

Applicant: l C/V l V ` Y (j�► VVU - - <
Permit#:
Date:
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
'ound in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE Disturbance total
labitat Name
disturbance-
Disturbance
disturbance.
Choose One includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/o
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts)
amount)
Dredge ❑ Fill ❑ Both ❑ Other (� a
`•�
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 171

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ��L'•i ii.`L-5T,r;1:7';: s
(Name of Property Owner)
property located at O
(Address, Lot, Block, Road, etc.)
on C N 1';' j" 'in -Ft ;�� i?; k. ,N.C.
(Waterbody) ~ (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location,
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
�: ns •r (� 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.)
wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner In emation) (Adjacent Pro erty owner Information)
Signature Sig r}(it '
Pint or -Type Name
Mailing Address a inTess l�