42384D - White

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`CAMA / DREDGE & FILL 1 RTC. il
iEN ERAL PERMIT Previous permit#
'New !Modification I '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/', /ZOO
/ / ,/ L Roles attached.
:Name Ai f4a e / (4)%i Project Location: County Su/e5a .P A
Pe,m -VAX 41 9 79 Street Address/State Road/Lot#(s)
Vfi//y State Ale ZIP Z$5462 .5e4'.0.re-
(f/I)) 2 —p27Fax#( ) Subdivision
:d Agent Gl..el 14✓,71/-4. City ZIP
❑CW PEW !6-PTA i ES ❑PTS Phone# ( ) River Basin 4.00i
❑OEA ❑HHF E IH E UBA ❑N/A Adj.Wtr. Body A✓ (140) (nat
❑ PWS: ❑FC: /�
yes / fi PNA yes /® Crit.Hab. yes / f) Closest Maj.Wtr. Body ales
Project/Activity "lop 5 tool /" 40,4_. lt,€
_ (Scale: I
:k)length 11.-'X . I
er(s)
Igth
nber /0�>< Z-0
I/Riprap length
distance offshore �� �
K distance offshore .......,.--^..„
annel ` " �.-
is yards V /V. y I"
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ip
>e/Boatlift 'r r , �/
Y i ✓.-i
Ildozing ,-
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Length 75 r 174 4 '✓- i//412 Aa
not sure yes •
not sure yes
urn: n/a yes
Yes •
ttached: yes •
ig permit may be required by: C�3/JA5Sd i r k See note on back regarding River Basin rt.

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DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual Applying For Permit: /ntC,c/yk-L L•��9sT
Address of Property: 9Z,8 d- 9 74 8_11912
(Lot or Street r, Street or Road)
su PP4 y, Nc. o1 oeieei wrc,E�
(City and County)
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 the:.
are proposing. A description or drawing, with dimensions, should be provided with this letter.
_ _ IL 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 28405 or call 910-393-3900
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 set
bck 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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Sign Name Date
•
Print Name

6 ER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
,mplete items 1,2,and 3.Also complete A. Signature
m 4 if Restricted Delivery is desired. IC� ❑Agent
nt your name and address on the reverse X � 0 Addressee
that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery
ach this card to the back of the mailpiece,
on the front if space permits.
D. Is delivery address different from Item 1? ❑Yes
cle Addressed to: If Y ter devery address below: ❑No
'D. / ©x 8� 7 coo. _.7
�� j ru 0 - a 5,
sf,�/f]/✓279 i L' a 8Qs3 w 3. Certified Mall 0 Express Mail W C) 1- T
Registered `J'Return Receipt for Merchandise ti
❑Insured Mall 0 C.O.D. -0 w 03
4. Restricted Delivery?(Extra Fee) 0 Yes r u Ills i
le Number W o
nsfer from service l 7003 1680 0000 8279 8935 L11 too $
rm 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 j �� C
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