55829D - Mathews

Street Address/ State Road/ Lot #(s)
-+6u0 --?,\ S�V-tt�
Subdivision W J A YS -E;'fAo1
ity 1 ZIP&�
one # �) 2" 52-C7�i River Basin L
Adj. Wtr. Body 1 hG-S nat r
Closest Maj. Wtr. Body ►Nl Un
CAMA / DREDGE & FILL h9
"ENERAL PERMIT Previous permit#
�Nevv ' ❑Modification ❑Complete Reissue DPartial Reissue Date previous permit issued
-ized by the State of North Carolina, Department of Environment and Natural Resources
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
R�,p attached.
t Name ! JaY� �- /"�(A��1f WS Project Location: County WSIi:IN
State ZIP 2�
Fax#()
;ed Agent
I A L& i RYU�1�
❑ CW
)kTEW '<PTA ❑ ES ❑ PTS
❑ OEA
❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
❑ FC:
yes / no
PNA yes /(no) Crit.Hab. yes / no
f Project/ Activity
ck) length _
1(s)
iier(s)
:ngth
tuber
d/ Riprap length
g distance offshore
ix distance offshore
hannel
bic yards .�
npi
PIE K !(eA>LNi"
rium: n/a es VIY no Mhfir`lilgJS
A
*u
(Scale: I // _
6-2
VA510
W�x-
(WAIVe11)
Attached: yes no
ing permit may be required by: {un IDW j
❑ See note on back regarding River Basin r
/. , 1 11,41 r A 1 t , , l .. -1-. �' .

RCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date l7
Name of Property Owner Applying for Permit:
M2&Y /, . MA i CMG--cz-)S
Mailing Address:
P. D. 60X '�Z65"6
s02F c-17Y,1u, <. k-�r
I certify that I have authorized (agent) kJ &NJU Y 13 R,0-&-J A� to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) k 3 v7q l L I F i ,
at (my property located at) % o GO Gv
<Sv�� C'(iyIC
This certification is valid thru (date)
Property Ow4ier Signature Date

cn Q�Q�
0 A q i 1 V)
r
1l -
ICE

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGS✓BOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to MAAq L-s N-A � W.< 's
(Name of Property Owner)
pt r
property located at f7l* 6 ly l ��
(Lot, Block, Road, etc.)
on C C_ , in c) G I Ao—y-'e6L)
N.C.
(Waterbody) (Town and/or ounty)
Applicant's phone #: �t4P-6)- Oailing Address• g,�{ % W � S
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 (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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
jN e, 4 c ,c, 6v (,�-I CT P6 /L +F(Act-(66
6AA-001/i(:�
(Information for Property Owner Applying
for Permit)
-/o6,0 &,,,
Mailing Address
(Riparian Property Owner Information)
( Signature
J"--f r r r fM

fVJ

C Divisian`0t Coastal Mgt. }habitat impact computer Sheet
)plicant: Mai M otNws
ate: I
,9/upA�
the name,
and units of
measurement
below the HABITAT disturbances for the application.
All values should match
)escribe
ound in your Habitat code sheet.
TOTAL Sq. Ft
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Anticipated final
(Applied for.
(Anticipated final
A lied for.
(PP
Disturbance
disturbance.
DISTURB TYPE
Disturbance total
any
Excludes any
total includes
an anticipated
Excludes any
restoration andlo
Habitat Name Choose One
anticipated
restoraincludes
ion
ttemp
restoration or
temp impact
restoration or
and/or
fpmn imoacts)
amount)_
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 ❑
Dredge ❑ Fill 0 Both ❑ Other ❑

3228
MARY R. MATHEWS
SEATON MATHEWS ee-19/530 N2
�7 /� / %) 702
P.O. BOX 2056
SURF CITY, NC 28445-0017
$2nd
fi4�2:�
Bank of America 4
l�
Bank of America Advantage®
. ACH RUT 053WO196
• ?6 140? Ili' 28
i:0 S 3000 L96'. 00060
Hw4m Clarke

■ 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:
�t 7
D L-1� SSA 1 SIC
114 i '40 -
A. Sin re
❑ Agent
❑ Addre
B. Received by (Printed Name) of III
D. Is delivery address different from item 1? 10 Yes
If YES, enter delivery address below: ❑ No
3. Servi Type
ertified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number
(Transfer from service label) 7009 2820 0002 7557 5241
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540
fl I N `�4 L U S E
Postage
S
>t!i.Y7
!�Yve
Certified Fee
$1.80
on
ReturnReceipt Fee
Postmark
Here
;� • �� I
Endorsement Required)
Restricted Delivery Fee
$0. ell
Endorsement Required)
Total Postage & Fees
Is
$-J• Y
07i 29/2010
gent To
t06 C
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2r PO Box No.f ` 6e-11 s� <� 6
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Form :00 August 2006
See Re�ersc for Instructions
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