41450D - Ross

CAMA/ I I DREDGE & FILL .i_. �n 4
aENERAL PERMIT V Previous permit#
Vew `iModification Complete Reissue `Partial 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 I 5A NCAC -7 N • 'Z JQ
lerl-Rules attached.
t Name k IE 0...o5S Project Location: County 0 NS L a,.,,
I/ l VE L-r*,a L-rsd Street Address/State Road/Lot#(s) _
.4.' a OS Ft 0 9 I State iN 4_...__ZIP 2_,4 Lib J i 1-1 V61-r''1 e, 1.....1
( I ) Sag • bSJ lo Fax# ( ) Subdivision S Lofv-T v►/igb b
edAgent City LADS PL.L-Q.y ZIP Za y('
❑CW L`/EW lisTA ❑ES ❑PTS Phone# (1 lc)) 305• ,co 6 River Basin\,11 tit
❑OEA ❑HHF ❑IH UBA ❑N/A Adj.Wtr. Body E.,4 n E?7 GrEE IL at i
❑ PWS: ❑FC: W ' 1•4Vf 4
yes / no PNA no Crit. Hab. yes / no Closest Maj.Wtr. Body
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nber 13
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not sur yes nog
s: not sure yes no
cum: n/a yes
yes 632)
kttached: yes ns _. f i /
ng permit may be required by: (DNS t oo...4 Lp s,. 4 71 See note on back regarding River Basin r

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•14-28t35 14:38 From: To:487 375 P. 1'1
PIVTSfON OF COASTAL MANAGEMENT
AD]AC_ENT RIPARIAN PROPERTY OWNER NOTIF'ICATIONRVAIVER FORM
Name of Individual Applying For Permit; -<-*6.
Address of Property: / 4 l
(Lot or Street#, Street or Road)
n 6.
(City and o nty)
I hereby certify that I own property adjacent to the above-referenced property. The individual
applying for this permit has described to me as shoe n on the attached drawing the development they
are proposing. A description or drawing, with dimensions, should be prop ided 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
Management, 127 Cardinal Drive Extension, Wilmington, NC 2S40_ or call 910-395-3900
within 10 days of receipt of this notice. 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 boat lift must be se!
bck a wininiu m distance of 15' from my area of riparian access -unless waived by me. (If ou
wish to wake the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement,
I not wish to waive the 15' setback requirement.
Cyvi,
U5
Name Date
Print Namet�.

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