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ADJ4CENT RIPARLA-K PROPERTY OWINI;R STATEMNT
(FOR A PIER/blOORI:VG PILL•YGS/BOAT'LIFTIBOATHOUSE)
I hereby certify that I own property adjacent to
I (NL a of Property uer)
property located at �� i n L� s i
(L-A Block, Road, etc.) r
C , is �Y N.C.
on (Waterbody) own and/or County)
He has described to me, as shown below, the development he is proposing at that location. end, I have
no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse =st be set
back a minimum distance of fifteen feet (IS) 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 ive that setback u• t.
._._.......-__ .....................�___—-------- --
D ION AND/OR D G OF PROPOSED DEVELOPMENT:
(To be filled in !dual proposing development)
7
�h
1f you have objections to what Is being proposed, you melt notify the Divislon of coastal Management (DCM) in write
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. Wilmington, NC
'DCM representatives can also be contacted at (910) 796.721k
No ea o se is considerga the snme a_ieo objedion if Xqa have been notified bX Certified I a
(Information for Property Owner/Applicant
Applying for permit)
3 a 2, �Y ►-e w f C a e✓t
Mailing Address
vn I C i
City/Stateizip
gigi— Ec,3 -393 1
Telep a Nu her
• l�
,vnnh,tw Date
(Riparian Property Owner Information)
Signature
Print or Typo Name
gam- )-70—atey
Telephone Number
— 5-- '20l I
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIEBA100RING PILI-VGS/BOATL'FTIBOATHOUSE)
I hereby certify that I own property adjacent to r✓IP s
(Name of property Owner)
property located at
(Lot, Bloc Road, etc.)
on
T G(1 , in fI n-z� a�/ , N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location, and, I 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 (IS') 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.
-----------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled In by individual proposing development)
S Pe 47-14*�-,:�/
1f you have objections to what is being proposed, you must notify the Division or Coastal Management (DCM) it% writing
within 10 days or receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. Wilmington, NC
DCM representativu can also bo contacted at [phone].
No ea o se is copsidered thesnme avfio ob'eclron i[X4u l0ve Ocen notified Certified a
(Information for Property Owner/Applicant
Applying for permit)
o �2 /� ") !wa L
Mailing Address
/` 14 e i , ItJC 2`151 --
City/StatclZip
Ll9 Sro 3 393/ --
Telephone Number
-- nmc
(Riparian Property Owner
Print or Type Name
(io - z6 �- ?5-rl P
Telephone Number
Date

A
LTIM
WWA
2�=��
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date
Name of Property Owner Applying for Permit:
Mailing Address:
rAe-I :�JJC �M�3
I certify that I have authorized (agent) `; /" 1 WI' 1 to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date)
2

C Division of Coastal N19t, Habitat Impact Computer Sheet
iplicaht: J'�(J �j( ����J Permit #:�-3Z
te:
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
bitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
tempi acts)
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)
1-4
Dredge ❑ Fill ❑ Both ❑ Other
�62�
Dredge ❑ Fill ❑ Both ❑ Other
�Z I
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 ❑

BRANDON D GRIMES 1123
9045 9th St 66-21 /530
Surf City, NC 2M45 BRANCH 77667
�J �
' Date
1 a to the
order of
$ z.0v.00
WACHO
Wachovia Bank, N
wachovia.com ✓ `
For Jo
i:0 5 3000 2 19i: 10 10 10 5 49 70 28'i' 1 1 2 3