59137D - Gornall

CAMA / DREDGE & FILL 4'
GENERAL PERMIT Previous permit #
New Modification Complete Reissue El Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources
Coasta' :",0burces Commission in an area of environmental concern pursuant to I SA NCAC
% t� Q Rules attached.
nt Name k j ck- �L� Y` L1 O � t Project Location: County Wict ,yN,�►(_k
i i !
s "(; ,(`'1 t:( A l.d �1 sc Street Address/ State Road/ Lot #(s)
1VlctoA stateMb zip 21 o2. i24 bolo"lln DyIVL
# ( ) }-q�lo Fax # ( ) Subdivision N W
ized Agent ) �CE� IkS O ZIP 'ty i-6 C vx x A Lt- zip n`-Ilo
,d CW , EW PTA v ES PTS River Basin Lc MA
❑ OEA ❑ HHF _ IH ❑ USA �] N/A I
❑ Pws: � FC: Adj. Wtr. Body � a � (A. � (nat
y / no PNA yes no Crit.Hab. yes no Closest Maj. Wtr. Body
• MIT, l VA
. .
lock) length
length
iumber
channel
NEI
EN
NEI
!ubic yards
amp
)Use/ B.atlift
71
I"r"
\
Bulldozing
ine Length
not sure yes
I
:gs: not yes no -
)rium: n/a no
Attached: yes Cno j
ling permit maybe required by:
"AWA-
1( El See note on back regarding River Basin
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CER'EMEu IMun -RgnM 1�RECEIP'1`,�,REO
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The purpose of this form is to provide proper notice to you as an adjacent riparian property owner to the individual or
individuals lived below, The LAMA General Permit application prccedwes require that applicants provide the Division of
Coasml Management confirmation that a written statement has been obtainod signod by the adjacent 6pwup prop" owner
indicating that they have no objection to the proposed work 1 that the adjacent riparian property owners have been notified
by carti Fed mail of the proposed work Men these forms are submitted to the adjacent ripwinn property owns by a inarin
consractor or other individuals acting as an authorized agent on behalf of the applicant.
This form was sent to you by the following iadlvitiluat or company designated by the applicant as as
authorized agent~
Authorized Agent's Signature Dow
Name of Individuai Applying For Permit . sc6 wl +�eL. j �s �$
Address of Property:
(Lot or Streett, Street or Road)
(City and County)
I hereby certify that I own property adjacent to the above -referenced property. The individual applying for this per
has described to me as shown on the angched drawing the development they are proposing,. A description or draw
with dimensions, should be provided with this letter.
I have no objections to this proposal.
If 'you have objections to what is being proposed, please write the Division of Conrad Man2gement,
Cardinal Drive Extension, Wilmington. NC 28405 or g11910-79&7215 within 10 days of receipt of this no
No response is considered the same as no objection ifrou have been noditied by Certified Mail.
WAIVER SECTION
t understand that a pier, dock. mooring pilings. breakwater. bout house or bout lift must be set ba
minimum dis-ttance of 15' from my are:► of riparian access-.untess waived by toe. (If you wish to waiv,
setback, you most initial the appropriate blank below.)
I do wish to waive the 1 S' setback requirement
I'iW.M wish to weiW the 1,5' setback requirement.
Sian Name m nvuD

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licant: k j� -� ;'�� �.,1, Permit
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Albe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
d in your Habitat code sheet.
DISTURB TYPE
tat Name Choose One
TOTAL Sq. Ft.
FINAL Sq. Ft.
(Applied for.
(Anticipated final
Disturbance total
disturbance.
includes any
Excludes any
anticipated
restoration
restoration or I and/or temp
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. rticle Addressed. to:
5-3Cvg 8
,r �, a c.,e �v,'fle j4 �-
A.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
Disturbance
disturbance.
total includes
Excludes any
any anticipated
restoration and/or
restoration or
temp impact
temp imoacts)
amount)
❑ Agent
❑ Addressee
B. Receivlfd by (Printed Name) C. Date ofl5elivery
D. Is delivery address different from ke ❑,Yes
If YES, enter delivery address belop, ❑ No
Cb
�Q
• 3. Service Type
11 Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7 011 0110 0000 8664 1211
(Transfer from service label)
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 .
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑