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4-6-03-2007 10:02 From: To:8429Ew
CEAMED WAIL - RETURN RF
CBMZj3&QUESTFD
PIVIS10 Of i MANAGEMENT
iu
The purpose of this form is to provide proper notice to you as an adjacent riparian property owner to the individual t
individuals fisted below, The CAMA Genan! Permit application pricedures require that appliCMacs provide the Div
Coasm! Maoagamcnr confirmation that a written smwment has been obmined signad by the adjacent riparian properi
indicating that they have no objection to the proposed work of that the adjacent riparian property owners have been
by terrified mail of the proposed work, Often these forms are submitted to the adjacent riparian properry owners by
contractor or ocher individuals acting as an authorized agent on behalf of the applicant.
This form was sent to you by the folkrwing Individual or company design aced by the applicant as ar
abthotized agent:
s Signature
I a Ce( I
Dace
Name of Individual Applying For Permir 1'ayyl
Address of Property: �_c! M m= v : e�J I: P - - Za(Lot or Street it, Street or Road)
460 \ Y"�
(City and County)
UV'.0vek C(�
I hereby certify that I own propeM adjacent to the above -referenced property, The individual applying for i
has described to me as shown on the attgehed drawing the development they are proposing. A description o
with dimensions, should be provided with this letter,
1_ <E 1 have no objections to this proposal,
If 'you hove objections to what is being proposed, please write the Division of CoaStal Naoage+
Cardinal Drive Extension, Wilmington, NC 28405 or call 910.796-7215 within 10 days of receipt of t
No response is considered the same as no objection if you have been notified by Certified ytail.
WAIVER SECTION
I understand that a pier, dock. mooring pilings, breakwater. boat house or bout list must be
minimum db`tttnee of 15, from my area of riparian access •_uadw waived by rase. (Ir you wish to
setback, you atast initial the appropriate blank below.)
1 do wish to waive the 1 S' setback requirement_
��� I do not wish to wnivf• rh,. iv c-avk-.L AMIEVA

C Division of Coastal Mgt. Habitat Impact Computer Sheet
:)licant : 6n,
le:
Permit #:
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd 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
disturbance.
Disturbance
disturbance.
litat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts)
amount
Dredge ❑ Fill ❑ Both ❑ Other
-4
Dredge ❑ Fill Both ❑ Other ❑
, Z
I Z
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. Article Addres��Y
3
A.
❑ Agent
❑ Addre
B. Received by (Printed Name) C. Dat 'of.D live
`l
D. Is delivery address d' erent from item 1? 11 Yes
If YES, enter delivery address below: ❑ No
3. Service Type
VECertified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) p Yes
2. Article Number (Transfer from service label)7 011 0110 0000 8664 0085
PS Form 3811, February 2004 Domestic Return Receipt
Dredge ❑ Fill ❑ Both ❑ Other ❑
102595-02-M-1540

HOLDEN DOCK & BULKHEADS 4261
GREGORY A & DOROTHY HOLDEN 66-1215/531
910-842-9732 HIS NCDL 4576438 HERS 5202642 840
1502 STONE CHIMNEY RD SW
SUPPLY, NC 28462 �0
�$oo
��W�WNBAK�W�j (" �p :..,
Supply, NC 28462` \�``-
unuru. ccan+aulbrk.cy 1
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1:05311 2 15 21:13000 L57530112042
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