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1 CAMA/ ❑DREDGE & FILL p'ri[.J NO 77822 A B
3 E N E RAL PERMIT Previous permit#
6New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
rized by the State of North Carolina,Department of Environmental Quality
:oastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC d - /ZO U
rr, ' i /II E� AlI`I i?/f ❑Rules hed.
t Name W Project Location: County ���iu C
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ig permit may be required by: �t/"L U See note on back regarding River Basin ri
_ocal Planning Jurisdiction)

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CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: W1 / (lQwt • /1 ,i.i.
Address of Property: I v 4((c d 6--t 1 &s P ' /ic y1 ,rt
(Lot or Stre , Street or Road,City&County)
Agent's Name#: Mailing Address:
Agent's phone#:
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing,with dimensions, must be provided with this letter.
o 1140_
1\jV,^ I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed,you must notify the Division of Coastal Management(DCM)in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at(910) 796-7215. 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, boathouse, lift, or groin must be set
back a minimum distance of 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.)
do
I do wish to waive the 15'setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
uktd-- id- „J'e4-1.4.0,5
Signature ignature
Attr a tris
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1ki, l 6 0 LGi Ads > es�c�ns
Print or Type Name Print or Type Name
16g brake. h-eoy- - Dr,
Mailing Address Mailing Address

C T FI • RETURN RECEIPT RE VESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: AM l ri1 i i
' A ciaMS
Address of Property: (Gird 6 •
ikAs 6►iif LE-5 P Id- /f/ard i
(Lot or t,Street or Road,City&County)
Agent's Name#:
AAailing Address:
Agent's phone#:
I hereby certify that I own property adjacent to the above referenced proe The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing A descri tion or drawin with dimensions must
ov'ded wi this sett r.
_ _ ___ I have no objections to this proposal, I have objections to this proposal.
if you have objections to what is being proposed,you must notify the Division of Coastal
writing within 10 days of receipt of this notice. Co Management(DCM)to
Flrylmington, NC, 28405-3845. pC� �pondence should be mailed to 127 Car�rtal Drive Ext.,consigt o the 84 as no o representatives can also be contacted at(910) 796-7215. No response is
Lion if haw bun notified b Certified Mall.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 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.)
ii I do wish to waive the 15'setback requirement.
I do not wish to waive the 15'setback requirement.
(Property Owner information)
�-j (Ada', ' "' 'ft .,�•., anon)
w4 l
Signature
r«r°C�tit 6 4df nrL t'e I)uffail
Pert or Type Name Print or Type Name
1a 6ratee
Maim Address a ,5+ M►tit0 A 5 �r.
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U.S. Postal Service"' U.S. Postal Service`'
CERTIFIED MAIL® RECEIPT CERtTIFIIic i oDYMAIL° RECEIPT
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Postage $0.55 _ f0.55
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PS Form 3800,April�OtS PSN �1e2.00,196a7
See Reverse for Instruuions �I:•I 1

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Consent for Use of General Permit 7H.1200
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i‘c (�Lot Number/Address:
County: ,.&14_0 Subdivision: if--4-4/4A)rt.)
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a:
(checCriterik all that apply)
v) Primary Nursery Area.
7 Less than 2.0ft deep.
❑ Greater than 2.0ft but less than 3.0ft.
❑ Submerged Aquatic Vegetation.
❑ Bottom habitat.
Comments: /�
MAMA — f/1/! � � Gam^-w(l Gt C /
v .� f)g 4 r©;��, 7E'
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pri ece, 7Y 22- 14A
Decision:
❑ Issue General Permit
❑ Elevate to Major Permit
NC Division of Marine Fisheries Representative Date

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