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C-03-2007 10:02 From: To.6429606
C;gRT_ME ED_MAIL - RETUR REC&IPT,,, "REQUESTED
■ Ir � a �� : u . . u
i' iJ 4 �� ► � i�♦ r S l ► \� a r�►� � � �♦LL
The purpose of this form is to provide proper notice to you as an ad'{accnt riparian property owner to the individual or
individuals listed below, The CAMA General Permit application prrcedures require that applicants provide the Divis,
Coasml Management confirmation that a wrinen statement has been obtained signed by the adjacent riparian property
indicating that they have no objection to the proposed worst 1 that the adjacent riparian property owners have been nt
by certified mail of the proposed work. Often these forms are submitted to the adjacent riparian property owners by a
contractor or other individuals acting as an authorized agent on behalf of the applicant.
This form was sent to you by the following individual or company designated by the applicant as an
authorized agent:
Authorized
Date
Name of Individual Applying For Permit: _ �wy� 12 1 e
Address of Property: l�1.��.t� ar ,
(Lot or Street It, Street or Road)
(City and County)
I hereby certify that 1 own property adjacent to the above -referenced property. The individual applying for if
has described to me as shown on the attgched drawing the development they are proposing. A description of
with dimensions, should be provided with this letter,
I have no objections to this proposal.
If -you have objections to what is being proposed. please write the Division of Coastal Manager
Catrdintal Drive Extension, Wilmington. NC 28405 or cull 910-796-7215 within 10 days of ttceipt of t1
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. boat house or bout llR must be s
minimum distunce of 15' from my area of riparian access-_ualesa waived by me. (If you wish to
setback, you must initial the appropriate blank below.)
ac�rd ► r--� -J o s' VW f
4 '' dltl I do wish to waive the 15' setbaclt requirement.
I do not wish to waive the 15' setback requirement. AV0-1;WA

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preA
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Division of Coastal Mgt. Habitat Impact Computer Sheet
licant: K�1 �1 S Permit*
-vibe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id 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.
'tat 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
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 Addressed to:
Oo V't nrf_i I C-7 .
ape- xf 2-150Z
A. Signaturej
X � V
ddressee
B. Received by ( Printed Name) C. Date of Delivery
4,/') A Aa - -, —
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
& A\ '\�\
3. Service Type
❑ Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number
(Transfer from servic 7 p 11 0110 p p 0 0 8663 6 7 81
PS Form 3811, Feb.. y euuv Domestic Return Receipt
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
102595-02-M-1540

•��...� « ovi_nncAus
GREGORY A & DOROTHY HOLDEN
910-842-9732 HIS NCDL 4576438 HERS 5202842
1502 STONE CHIMNEY RD SW ��
SUPPLY, NC 28462 s—
4225
66-1215/531
840
B�OYIIt on
WACCAMAWBANK
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WILDLIFE PORTRAITS®