59143D - Kelly

_ CAMA / DREDGE & FILL
GENERAL PERMIT Previous permit#
.New Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
�r=
orized�by the State of North Carolina, Department of Environment and Natural Resources ?40
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
} / Rules a ched.
nt Name /`� �f y Project Location: Courl &4 ='l
s 2/ 10 5 II . "//n/, Jgv-e Street Address/ State Road/ Lot #(s)
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# (1yv) '10 ',Soya Fax # ( ) f Subdivision
ized Agent � �/�5 �G+ C.r CityZIP ///SCti
d CW J EW LwPTA LES Ci PTS Phone # ( ) r� River Basin
OEA - HHF ❑ IH ❑ UBA ❑ N/A
PWS: ❑FC:
Adj. Wtr. Bold y6wlk S C Ir (nat
/�
yes / no ' PNA yes / � Crit.Hab. yes / no Closest Maj. Wtr. Body ( rte.., s44++
)f Project/ Activity 7"" S. �� Gi �TP $
5-1
l-p .
ock) length
'ength
umber
ad/ Riprap length
vg distance offshore
iax distance offshore
:hannel
ubic yards
imp
Ouse/ Boatlift
Bulldozing
ne Length
not sure yes
gs: not sure yes 00
)rium: n/a yes 64
yes
Attached: yes
Ping permit may be renuirec
(Scale: ) ��

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—; IIP—wlyft — W-m -c -he 15' foetlx%L-4 rrqt-ircr.WrK
?sift UA4'vrish t6 the 15— qe:tvstk
Date
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CER rlMED MAIL -- RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER
FORM
Name of individual applying for the permit: %� G G y
Address of property: "-2/"-�; 5 N- L u""Ha...-/
(Lot or streeW, street of road)
(City & County)
I hereby certify the I own property adjacent to the above referenced property. The
Individual applying for this permit has described to me (as shown on the attached
drawing) the development they are proposing. A description or drawing, with
dimensions, should be prodded whit this letter.
have no objections to this proposal
If you have objections to what is being proposed, please write the Division of Coastal
Management,127 Cardinal Drive Extension, Wilmington, NC 28405 or call (910)
796-7215 within (10) days of receipt of the notice. 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, lift or
sandbags must be set back a minimum distance of 15' From my area of riparian
arxess unless waived by me_ (If you wish to waive the setback, you most initial the
appropriate blank below_)
�do wish to waive the 15' setback requirement
I do not wish to waive the 15" setback requirements
2 / 2-
Signature _..._....__, '^. Date
./ 1�)6kgZ4 LQ r--

CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina, _
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC.Subcha er,7.k{ .o203.
applicant Name Phone Number
address
'ity - State Zip
'roject Location (County, State Road, Water Body, etc.)
"ype and Dimensions of Project
'he proposed project to be located and constructed as described This certification of exemption from requiring a CAMA perm
bove is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following expirat
uirement pursuant to 15 NCAG 7K .0203, This exemption to a re-examination of the project and project site may be necess
LAMA permit requirements 'does not alleviate the necessity of to continue this certification.
our obtaining any other State, Federal, or Local authorization.
SKETCH (SCALE:
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B 2"
P 6 2011

plicant:
te:
)�Pf jZ
Permit #: ;-�? % q3
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
�itat 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
y
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 ❑

WESTERNI Ianna P-yabwatwolls
V M._.--
WESTERN UNION FINANCIAL SERVICES INC. - ISSUER
NA., Grand Junadon, �°"_.__.do--- Engiew000d, Coloradc
Banran
k Grand JuncWn_owarm_,___
14-427675946
T Uy54_ -..+"
L 44'2176i` a4t4 L Q(0(i()£i3.
PAY EXACTLY TWO yUNDRELD DOLLARS A01 NO LEP<10 PAYMENT FORJACCT. #
PAY TO THE 7
ORDER OF
�i URCHASER'S ADDRESS ,�a HsensswrurvpE
1 ,-1 ,
1: 10 2 1004001: 40 "4 2 76 7 594E,4ll