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�CAMA/ DREDGE & FILL N9 4
EN ERAL PERMIT Previous permit#
!New Modification Complete Reissue Partial Reissue Date previous permit issued
ized by the State of North Carolina,Department of Environment and Nat I sources
:oastal Resources Commission in an area of environmental concern pursuan I 5A NCAC -7 14. 1 I.C›
Mules attached.
t Name ViZ 4L7rq v V1.1IT t Project Location: County DNS La w
In"3 Qjv Ex_yrts t= b2 Street Address/State Road/Lot#(s)
G.AD FE.0.Q--y State+)L ZIP Z,3`l Lie. ►cl V.'s,/ t;4 S'lb r 171`
(ci 1-z) 413- I i 30 �gFax#( ) Subdivision
ed Agent h i� Y A(LTJ C— City, 0 .(4.O5 F0 a ?-1 ZIP ,. -7' w l
❑CW ,W PTA ❑ES Li PTS Phone# ( ) River Basin W .
❑OEA ❑HHF ❑IH ❑UBA ❑N/A S"c��L
Adj.Wtr. Body G,,✓ i i
❑PWS: ❑FC: Closest Maj.Wtr. Body 0 e v✓ 1ZZ V D 2
yes / o PNA Mil no Crit. Hab. yes / no
'Project/Activity -1-tajrA L L. 1 1a2)( 1 to 71 A'T .'✓LM L X yL Pr Q 0- 0 t•-)
N o xL3iZ G' "re R. it i
(Scale: -
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i(s) 14 x ( b ( r--
ier(s) ..�,1 w 1 wf g 1& {C 1L Y V -,
ngth {�f �
-Tiber ((1(
1/Riprap length `yell
distance offshore
x distance offshore
cannel
)ic yards
np IIC
se/Boatlift
ulldozing
1 Ex1ri'�
/ (IY ,ID ,
e Length -1.7
not sure es no - _ .
s: not sure yes no
'cum: n/a yes no P L P L
yes 2kttached: yes
ng permit may be required by: 01.35(,.D1..} COLA✓"f y . 7 See note on back regarding River Basin r

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(0B/2004 g1:29 5402888616 JERNIGAN PAGE 01
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ADJACENT RIPARIAN PROPERTY OWNER NO IIFICATION/WAIVER FORM
lame of Individual Applying For Permit: Wit 11,`f 1 a, /9/I `-tP
ddress of Property: ie( VerC5 Ap
(Lot or Street#, Street or Road)
(City and County)
hereby certify that I own property adjacent to the above-referenced property. The individu
aplying for this permit has described to me as shown on the attached drawing the development the
-e proposing. A description or drawing, with dimensions, should be provided with this letter.
I have no objections to this proposal.
you have objections to what is being proposed, please write the Division of Coasts
fanagement, 127 Cardinal Drive Extension, Wilmington, NC 28405 or call 910-395-390
ithin 10 days of receipt of this notice. No response is considered the same as no objection i
►u have been notified by Certified Mail.
WAIVER SECTION
inderstand that a pier,dock, mooring pilings, breakwater, boat house or boat lift must bi
t bck a minimum distance of 15'from my area of riparian access-unless waived by me. (I
►u wish to waive the setback,you must initial the appropriate blank below.)
/‘/< I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
n Name - Date
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