39068D - Madison

KICAMA/ }`_DREDGE & FILL
GENERAL PERMIT Previous permit#
KNew .__I Modification ❑Complete Reissue LIPartial Reissue Date previous permit issued
)rized by the State of North Carolina,Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to ISA NCAC 70ZUU
it Name �; hn �4.d/s0
❑Rules attached.
Project Location: County E rz,nSLcJ/C
; a?5 (0/ 0/(I b at) y-;iLi iti toad sW Street Address/State Road/Lot#(s) . /
✓5`i(.(.(0 He. State A/C zip �8.qs9 6/c-/ /LI e y.5d'in,11219 1Ve 500
V.( ) Fax#( ) Subdivision
zed Agent Lh5a/ t27,t, tZ City 5Aa l(o-ifc zip, 81/$-`
i ❑CW '14EW APTA ❑ES ❑PTS Phone# ( ) River Basin 4l /i7
❑OEA ❑HHF ❑IH ❑UBA ❑N/A
Adj.Wtr. Body.517 �- /� / � at,
G M.i
❑ PWS: ❑FC: /^
yes no PNA yes / no Crit.Hab. yes / no Closest Maj.Wtr. Body t-lu lie / i v e..-L
If Project/Activity /r75/a (/ - Boa r L i S 9 A/c-to iC/oa 61y bock- (v e,si c 1,
_- --i / 5—1 rib) (Scale: /
Eck)length le. A/7
!n(s) $)( Ito
pier(s) , — __4_
ength t r-
amber iir I 1
ad/Riprap length ;._...— t + 'y --t.— — . IP __ ' _--.._.
ig distance offshore -,3 )—�._—
tax distance offshore I-- ;
} 1
:hannel t • { • • 3 �-
�1i
— I —_
ibic yards -
ImpIN 1 I J...I I WI 7 L r-.. ...._ �.�_ # -
}
use/Boatlift 131 1 3 if � 0
'� _
Bulldozing W -.— :--- V' rIY
i t%
ne Length ASS 4 1 ... a %` { f 1 `� } —�
not sure yes no I 7. i i 1�/
gs: not sure yes ® ,-.. � i. i!� !I v -0 I
rrium: n/a yes — ..... 1._ 1 �V ui i
J
yes ® _ } - ; I , _ - --_
Attached: y s f 1 i
ling permit may be required by: ,_/i//1SLtJ/C Co/I/-)7 0 See note on back regarding River Basin

GENERAL PERMIT COMPUTER FORM
APPLICANT NAME: fz aii1/t, 7- Ma cirsc ;-,
ADDITIONAL NAMES:
AEC DESIG: FLU I DEVELOP AREA: U f PROJ DESC: - 12
(Will only take 6) ————
(Will only take 1)
WORK: Tr- F.i(&' t31✓ /3 i3
(Will only take 4)
SL i3 3
MAINT:
(Will onlytake 4)
IMP: �}W .2)6 (o •
(will only take 6)
ACTION EXPIRATION
DREDGE &FILL REQUIRED: I Z5(0z( (I/ZS/p
C.AMA MAJOR DEVEL REQUIRED: $1 ZG f o 11 J 25 16 if

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/10/2004 11:00 9107546718 PAGE
D VISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual Applying For Permit: 7 / -/
Address of Property: / s ,
(Lot or Street #, Street or Road)
(City and County)
I hereby certify that I own ro e p p rty adjacent to the above-referenced property. The individi
applying for this permit has described to me as shown on the attached drawing the development th
are proposing. A description or drawing, with dimensions, should be provided with this letter.
I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coast
Management, 127 Cardinal Drive Extension, Wilmington, NC 28405 or call 910-395-39C
within 10 days of receipt of this notice. No response is considered the same as no objection
you have been notified by Certified Mail.
WAIVER SECTION
understand that a pier,dock, mooring pilings, breakwater,boat house or boat lift must best
ick a minimum distance of 15' from my area of riparian access-unless waived by me. (If yoi
rish 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.
ame
Date
int Name `' � r w

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