86726A - Wilson, Jeffrey

k, KICAMA X DREDGE & FILL
Na 86726 a C D
Previous
IAl
; GENERAL PERMIT
permit
DAW, previous permit issued
JK'New DModification F-
�­] Partial Reissue
AN aud--,12ed tyled*Stam, Of North CA1010na, 17"4tn,qntof FMvlMw""ww0,-%4#Y "'W010cailt4taf Area of emi—mental concern pursuanx=
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Riparian wa,vef Aitache& yes
A building permit/zanjrg permit rtW be required by:
Permit Conditions
TAWPNVNEV,1WJSUFFlEFk (arcle one)
Sft note on back reg3rding River Basin rules
Sees additional notes/conditions on back
Check #/Money Order

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERED
dame of Property Owner:
Address of Property: qt�BUJP_ tj,, 1�-_AeA�OA CL34
(Lot or Street #, Street or Road, City & County)
Agents Name #:
:ger is phone #:
Mailing Address:
erey ce, iify that i own property adjacent to the above referenced property. The individual
aoni,rinr-, fnr this permit has described to !tee as shown on the attached drawing the development
^.ey are proposing. A description or drawing, with dimensions, must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
,'f you have objections to what is being proposed, you must notify the Division of Coastal Management
fDUVI) in writing within 10 days of receipt of this notice. Correspondence should be mailed to 01 S.
Grif; in St., Ste 300, Elizabeth City, AlC, 27909. DCM representatives can also be contacted at (252) 254-
3901. No response is considered the same as no objection if Lou have .been notified by Certified Mail.
WAIVER SECTION
ECEINIEGat a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
mist be set back a minimum distance of 15' from my area of riparian access unless waived by
wish to waive the setback, you must sign the appropriate blank below.)
1uL'T"eu
I do wish to waive the 15' setback requirement.
DOM- U I do not wish to waive the 15' setback requirement.
,Mailing Address n
vityiJtaI l7'
�- U l
eie�hone Number/Email Address
(adjacent P,, ' et Owner information)
Sib\ ature"
Print or Type Name
i ZGi ►V �A 2"A��V
A/lailing Address
City/State/Zip
Telephone Number/Email Address
Date I I Date` '
*Valid for o ,e calendar year after signature* ��1� Revised 2017

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I-J?kM4rl

L DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
0NERT!F!ED MAIL - RETURN RECEIPT REQUESTED or NAND DELIVERED
Name of Property Owr
Address of Property:
Agents Name #:
.agent`s phone #:
(Lot or Street #, Street or Road, City & County)
Mailing Address:
1!-. by certify that 1 own property adjacent to the above referenced property. The individual
anni;ring Tor this perm;* has described to me as shown on the attached drawing the development
:hey are proposing. A description or drawing, with dimensions, must be provided with this letter.
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 4011 S.
CYifr'in St., Ste 300, Elizabeth City, NC, 27909. DCM representatives can also be contacted at (252) 264-
3901.Ito response is considered the same as no objection if you have been notified by Certified Mail.
pWAIVER SECTION
A l,' � i�a ii . dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
r list be set back a MP
distance of 15' from my area of riparian access unless waived by
Jftoy y%to waive the setback, you must sign the appropriate blank below.)
1 do wish to waive the 15' setback requirement.
`E
1 do not wish to waive the 15' setback requirement.
Printor Type Name
r.
(Adjacent P,roperty Owner information)
Signature"
V) o-sFPN Pti ���,,NY404
Print or Type Name
`? a _I� 01 Z
Mailing Address
�71_ I L) Q_--Jq3�_ (" �=_ I N , C . 2_-7_1�3 1 -
Sii!iiSpa re/Zip City/Sta telZip
-7�-_ oho ,Number/Email Address Telephone Number/Email Address
, �; zaz�
Date *VDate
*Valid for one calendar year after signature *�'tt Revised 2017

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