59168D - Puknys

❑ CAMA / ❑ DREDGE & FILL
ENERAL PERMIT Previous permit #
ZlVew ❑Modification El Complete Reissue ❑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 concern pursuant to 15A NCAC ZGU
�p Rules attached.
' t Name { v% Project Location: County FKVrlSW`i c t L,
�-7 Street Address/ State Road/ Lot #(s)
L KS�.�-� r�+ ac StatelyC. ZIPZ�41[p2 5I U i�� ` -r-Gt+
#) +Og Fax # () Subdivision VJ/A
`izedAgent h rVl�1 City ` Ihbf �}i(,Lk. ZIP l 1?.
!d
❑ Cw p"EW ; PTA ❑ ES ❑ PTS Phone # (pp- 110 }5 � �i0� River Basin W Yh
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
71 PWS: ❑ FQ
yes no PNA yes /(no) Crit.Hab. yes no
of Project/ Activity
lock) length
-m(s)
pier(s)
length
camber
aad/ Riprap length
ivg distance offshore
nax distance offshore
channel
:ubic yards
amp
Ouse/ Boatlift
Bulldozing
ine Length tJ
not sure yes no
cgs: not su yes no
orium: n/a no
yes no
r Attached: yes ( no .
Adj. Wtr. Body d 1,U N1 Ad I. N`L:;;`T at
Closest Maj. Win Body A\ylw
(Scale:
ding permit may be required by: F-1 See note on back regarding River Basin
- ^- -u I-2nn n,.,I „11 1'.1 cLI 'J. _1 —.0-1 1

4 �MEM.NON.
lCDENR North Carolina Department of Environment and Natural Resources
Division of Coastal Management Dee R
Beverly Eaves Perdue James H. Gregson SE
Governor Director
AGENT AUTHORIZATION FORM
Date:
Name of Property Owner Applying for Permit: .
Name of Authorized Agent for this project:
Owner's Mailing Address:
------------
Phone Number
Agent's Mailing Address:
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
(my property located) at -i3k
wj"g\ �
This we ication is valid thru (date)
f � 2
_ _ n2tP

-IAND DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FORA PIER/MOORING PILINGSBOATLIFT/BOATHOUSE)
I herebycertif that I own property adjacent to �rope�rtyO
s
Y
( me oner)
property located at
(Lot, Block, Road, etc.) \ _
on , in snT �-l�.Y \��> N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 5��Q� Mailing Address:
b-)9-1110%- 6C�o,Y—
H
e has described to me, as shown below, the development he is proposing at that location, and, IZ
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 (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 do not wish to waive
I do wish to waive that setback requirement.
-------------------------------------------------------------------------------------------- - -
DLSCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
3i�D ar— k
Mailing Address
(Riparian Property Owner Information)
-49i,
Signature
�_—
D-�•.t r T-0 Tel-krna

0 MAIL
CERTIFIED MAIL — RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
14ame of Property Owner:
Address of Property:
(Lot
Applicant's phone #
Mailing Address: 66t P—)Q96-\
I hereby certify that 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 of drawin
with dimensio must be provided with this letter.
--,/#}i 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 Ext
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 flail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a minimum distance of
15' from any 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.
I do not wish to waive the 15' set back requirement.
(Property Owner Infor t'on)
gnatture
n
Print o Type Natne
Mailing Address
(Ripap"_PropertyOwnerjnformation)
re
Vim% LJ ,Zyl1�
Tint or Type Name
I�W 4/7e'94 /z,
Mailing,Address

Ocza r,
"a,
�' ✓ � �1 I�S�C
` 1

Acant: kay
�/y� �d Arkm Pj Liu S Permit #: l ,
1 r
e: J
cribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id 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
I l
2
mplete items 1, 2, and 3. Also complete
-n 4 if Restricted Delivery is desired.
nt your name and address on the reverse
that we can return the card to you.
ach this card to the back of the mailpiece,
on the front if space permits.
icle Addressed to:
2Z.125
-S 2-2z
A. Signa
X
B.-R y (Rented
r Is deliv a
If YESiter deli
1NDOLpysTArON _
FEB 2 7
U Agent
❑ Addressee
.) C. Date of Delivery
from item 1? ❑Yes
tss below: ❑ No
3. sdr9m Type 'V/
4�Rist
�'�eturrt
Tess Mail
Receipt for Merchandise
.O.D.
4: RastapWd Delivery? (Extra t-ee)
ticle ansferurom 7009 1680 0000 2205 9557
ansfer from se►vtt�
orm 3811, February 2004 Domestic Return Receipt
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
❑ Yes
102595-02-M-1540
r- �nrr�r►�raaFnc.�.0
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O ru Postage $
ru
Certified Fee
0
p Return Receipt Fee
O (Endorsement Required)
O Restricted Delivery Fee
(Endorsement Required)
O
$0.45 0470
$2.95 18
Postmark
$2.35 Here
$0.00