54038D - Kouba

AMA/ ❑DREDGE & FILL r-
ENERAL • PERMIT Previous permit#
ew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
rized by the State of North Carolina,Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC 2,4 /2 a C
LI}R 11es attached.
t Name $e U(" t / i4W.1" ,61 X py6R Project Location: County ea kt.-5t✓it/C
. _eCil 497, ,' ( LA.- e-- Street Address/State Road/Lot#(s) AO S Sf G 7
8 , .rr State /i C ZI P ..Z Fie:? 1,3 Gri° T f _7)oe .
( ) Fax#( ) Subdivision
zed Agent t;�/1 e o-i de-- City fe.,Zclo,, (3*4c 2 ZIP 1bYz
d , cw EW PTA •ES ❑PTS Phone# ( ) Over Basin Ly,,
E.OEA . HHF ❑Ili UBA ❑N/A
Adj.Wtr. Body C1 ,.J 9 L o f G✓s✓ (pat i
❑ PWS: L FC:
yes / no PNA yes Crit.Hab. yes / no Closest Maj.Wtr. Body �1'�✓L✓
Af Project/Activity 6 d Q ap p-74/, t- / /‘' 1;4 i S 7,,..) "PZ/23.aC
*
(Scale
lock)length EX aj A,.
,m(s) c,4 ,5 4,-, I_ -...., —-r --1 —
pier(s) 11j — _.._—I
length 1 j
lumber
:ad/Riprap length ' ��1 i l i
vg distance offshore _-
lax distance offshore j. —. 0 ??' - d A
channel i
ubic yards
{ 1 1
)u5 tlift)13 jC/J'_ 1 ' : I 1
f 4 op, 44 i
Bulldozing 13
-t,‹.1 .., j/A f
i n e Length U i/ I i ' ! I I�not sure yes �7 ■
Igs: not sure yes Y/
L _- _ (,4
)rium: n/a yes �/� y P
Ai L l
yes ' I Ip C ti.,. i �' U
1 �y�`p' A
1 I i ! I "'Attached. � no '''// l )/ D /
ling permit may be required by: //0 deN !1 P.9 c /4 I See note on back regarding River Basin
._ . . _ .. . .4I . - 1 1 //.` -% 1i . ... ii. ... .- i .

-DIVISION OF COASTAL MANtGEMENT
ADJACENT RE-'. __ 1 PROPERTY OWNER NO l 1rICATION/WAIVER FORM
Name of Individual Applying For Permit: S4 o- I 'aih,4
Address of Property: 10 5- Sc.ov-k Snyvv e / i.
(Lot or Street #, Street or Road) '�'"1
el (? cL
(City and County)
I hereby certify that I own property adjacent to the above-referenced property. The indi'
applying for this permit has described to me as shown on the attached drawing the developmer
are proposing. A description or drawing, with dimensions, should be provided with this let
_s I have no objections to this proposal. e"--4". 7fr ¢ 1
If you have objections to what is being proposed, please write the �
Division of CI
Management, 127 Cardinal Drive Extension, Wilmington, NC 28405 or call 910-39
within 10 days of receipt of this notice. No response is considered the same as no objeci
you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house or boat lift must
bck a minimum distance of 15' from my area of riparian access - unless waived by me.
wish to waive the setback, you must initial the appropriate blank below.)
!L1
I do wish to waive the 15' setback requirement. T d
I do not wish to waive the 15' setback requirement.
6/•
Stun me Date

I V-Picot ATI/
NCCODIR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Bovar1y Eaves Purdue,Governor Janne H.G'egson,Director Dee FreA*.rtfn,Secrait30,
AGENT AUTHORIZATION FORM
Date
Nome of.U'repe O,t,:fner Appirine forPermit:
Mailing Address:
(• 3
q e 41 j that brave sushni fzzd(Agent) oi.3 on
h.. 39-:f fAr ffiila 3lSa-a -§fa 33:13Tii3"a3:3a 3 a
3:r s`$n _'_ �`'s 211 c3AMA 1• 3 M%
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ene-4
tsies~-YS 7/(fi ndCC 9/L LPL?

R: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
•fete items 1,2,and 3.Also complete nature
• if Restricted Delivery is desired. T ,,. , • - ,. P Agent
our name and address on the reverse X w lX� ~ `'' 'i:••ressee
:t we can return the card to you. B. Received by(Printed Name) C. Date of Delivery
this card to the back of the mailpiece, S- 23
the front if space permits.
D. Is delivery address different from item 1? ❑Yes
Addressed to: If YES,enter delivery address below: ❑ No
raa+ (5a nJa Goff)(+-k _ .
,,-0one llbum Place
rl.be.! tic a star 3. Service Type
I ❑Certified Mail ❑ Express Mail
Cl Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
Numb .J-rg
erfromeservice 7007 2680 0002 4233 7618 �: o f u
3811, February 2004 Domestic Return Receipt 102595-02-M-1540:0 E •
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