60697D - HC

:AjAMA / ' DREDGE & FILL NO. 6O
GENERAL PERMIT Previous permit#
New ❑Modification LJComplete Reissue F-Partial Reissue Date previous permit issued
orized by the State of North Carolina, Department of Environment and Natural Resources _
Coastal Resources Commission in an area of environmental conce n pursuant to 15A NCAC �� •-
C I /1,. �ry � :` j�lafr� Rules attached.
t`Nra/me lil } , �.y� Project Location: County rUnSWick,
s1 hi mniev- PlAci Street Address/ State Road/ Lot #(s)
( Statee_ ZIP��
Fax # ( ) Subdi(vision j I
ized Agent cjl JZi{ S ity C )0106 to ISir ZIP
d CW X EW PTA ❑ ES ❑ PTS one # ft) 1 SZ River Basin W
❑ OEA ❑ HHF _ IH ❑ UBA ❑ N/A Adj. Wtr. Body Cav A.(" (nat
❑ PPWS�: ❑ FC:
vPS / nn 1 PNA . &c i47) r—t- w.k „o� ✓„ `, Closest Maj. Wtr. Body Al low
A Project/ Activity
lock) length _
'm(s)
pier(s)
length
umber_
ad/ Riprap length
vg distance offshore
iax distance offshore
channel
ubic yards
Imp
)use/ Boatlift
B Idozing
am - x a
ne Length JV
not sure yes no i
gs: not si rg yes
)rium: n/a es no
Attached: yes ( no) -__
ling permit may be required by:
❑ See/ note on back regarding River Basin
f/f&' nuA n ^1. 1

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date % i Z — i -z-
Name of Property Owner Applying for Permit:
Mailing Address:
67 p4't2 y N C Z -7 > �
I certify that I have authorized (agent) GJ A/"51 to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) I Axw D c, .-
at (my property located at) 7-, ( G. c lAt--) 5 % 0 j l "�
This certification is valid thru (date) / c — Z C — / Z
Signature Date

vU mni6
CERTIFIED MAIL, - RETURIN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
name of Property Ova
kddress of Property:
((�
Applicant's phone 9: Cl ! Cl—vso 19 �/ �Mailing Address:
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this permit
las described to me as shown on the attached drawing the development they are proposing. A description of drawin
Nith dimensions, must be provided with this letter.
_�_ 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 Managemeut (DCK
in writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.
bVilmington, 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 flail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a minimum distance of
l5' 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' set back requirement.
_ Ae I do not wish to waive the 15' set back requirement.
(Property O_"er Information)
Signaw
or t YDe Name
I n it, N � I
Mailing Address
is t-AteI ft.in
(Riparian Property Owner Infor at' )
S nature

8X20' Dock: System
3X 18' Ramp

2 * f O0 o1$ ruvr I
�

pplicant: t
C& , C. � I� I1'1 u—v Permit
ate:
9/_Z51-:2-
,scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet FINAL Feet
bitat Name
DISTURB TYPE
Choose One
(Applied for.
Disturbance total
includes any
(Anticipated final
disturbance.
Excludes any
(Applied for. (Anticipated final
Disturbance disturbance.
total includes Excludes any
anticipated
restoration
any anticipated restoration and/or
restoration or
temp impacts)
and/or temp
impact amount)
restoration or temp impact
temp impacts) amount)
Dredge ❑ Fill ❑ Both ❑ Other
6
1(,o
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Pnnt 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. Article Addressed to:
Kenneth B Roberts
144 North Sardis View Lane
Charlotte, NC 28270
rAl ature
Agent
❑ ddressee
B. Received by (Printed ame) C. Data of Delivery
D. Is delivery address different from Item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. ce Type
Certified Mail ❑ Wass Mail
❑ Registered Vhetum Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7008 0500 0000 3889 1157
(transfer from service fabeq
PS Form 3811, February 2004 Domestic Return Receipt 10259"24A-1540
■ 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.
x --- ❑ fit., -�
❑ Add
B. R iv by (Printed Name) C. Date of Delhiery
X /O -id
I D. Is delivery address different from item 1? ❑ Yes
1. Articta Addressed to: If YES, enter delivery address below: 13 No