53904D - Medley

J.CAMA / i 1 DREDGE & FILL r-
3ENERAL PERMIT Previous permit#
.New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
prized by the State of North Carolina,Department of Environment and Natural Resources i 1
:oastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC 1
11 1�RulPca1cl1
attached.
it Name (A I A YIt )A e 4 Project Location: County NI,W '
ICJ 1.K. nvkl t ''( Street Address/State Road/Lot#(s)
1.c1Ai AIk IOi/tat State iv:. ZIP A"1SO R U NI. 1,ilea-tat. Lv1 K.
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:ed Agent 91 UWQ14 ti'1� Cityit V V Y, �1 'U t VI-
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❑CW W 1$PTA ❑ES ❑PTS Ph'or # (4 I D )U VI- 9) It River Basin(, ) C
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❑OEA ❑HHF ❑IH ❑UBA ❑N/A Adj.Wtr. Body 13/A141( '�'1 Q 11 iu I (nat /
❑ PWS: ❑FC: A
yes (ono, PNA yes no Crit.Hab. yes / no Closest Maj.Wtr. Body 1 { Ch
fProject/Activity kQMi Q' S 11-J U1 jt t wt ,(AA-It f\{Lk tt l ticaJr t 44
(Scale: I�;
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g distance offshore I (! �{Q
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ax distance offshore 1 1 I i INA,tab n 4 v4441
hannel 4 ' 1 V61 ' lift*
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Attached: ,.....r_ V 1 II ( p01?Y
moo✓ no
ing permit may be required by: I MIA /} �11h1501I� 13(ack I See note on back regarding River Basin r
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AstuA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H.Gregson
Governor Director Dee Secret
AGENT AUTHORIZATION FORM
Date: e -10 —Oct
Name of Property Owner Applying for Permit:
Mark F Medge y
Wailing Address:
W ,‘3 h-\-5\i M ( t!e,G h 1\ -
'hone Number: AID 670 - c 'Z,S
certify that I have authorized (agent) 6 Occ--v r ; h r`, to act on my
ehaif, for the purpose of applying for and obtaining all CAMA Permits necessary to install or
onstruct (activity) C w 600t,-V\ -k ct-\d R eto c P;\e s
t (my property located at) l 0 Cha r A e( cc (3 L
his certification is valid thru (date) 10 - -Co - O

i, 6re jo-y 6 N c hunAtA
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to M&rk ti\eA`G 's
(Name of Property Owner)
property located at 10 N r h Or
(Lot,Block,Road,etc.)
on , in \'‘)(1.10.5L, 1L t?fah ,N.C.
(Waterbody) (Town and/or County)
Applicant's phone#: 6 LO- 61 -$S Mailing Address: ID N L nn .A 0(
wf i o4c, -tt e, Q a k\ iJ c,
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 pierhnooring pilings/boatlift/boathouse
must be set back a minimum distance of fifteen feet(I5') 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
Ai do wish to waive that setback requirement.
ESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
Mailing Address Signature
-851ch G
City/State/Lip c 5 _1 SO Pilint or v. Pe Name
_

(/ nn{�
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING FILINGS/BOA TL IFTB OA THO USE)
I hereby certify that I own property adjacent to Mark- Pi\ y 's
(Name of Property Owner)
property located at to CANa ,n A O
(Lot,Block,Road,etc.)
on , in \1{ , h-�Svi1� L
ecCc.�1 ,N.C.
(Waterbody) ' (Town and/or County)
Applicant's phone#: G 2D_ q tb S Mailing Address: ((7 l) Carr i Dr
We \kSv\,fie (�euU� N L
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)
See.- A+A-atit
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
OJ C �`C I)-v
Mailing Address
k Ltc; (k,c SCD
City/State/Zip sS 4 O v
Print or Tyne Name

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ti
10
BOATZRIGHT INC.
817 BERWYN RD. 910-795-0228
WILMINGTON, NC 28409 DATE V VPAY
.-
} TO THE 0 Ii ' R is zoo-
T ORDER OF i
t'YL.'l v!),C 4" 6/1 i LcY DOLLARS
11 First Citizens
Bank
firstcitizens.com
0\rft,1ley �j��I�W
FOR
POO 1,0030 1:053 L003001:00353 2 L08 L550°