72198_Floating PWC Dock_20180801

NC
toad -198, C
CAMA _E1DR EDGE & FIL.C"' N272 -D"
GENERAL- PERMIT revious-permit #
New 0 Modificaticin EICO'niolete Reissue El Partial Reissue Date previous permit.issued
n Staie�bt North Carolina, Department of Environmental Quality
As dutho,fted b the . - - '. o �C
and the tal, esburc6s� Commission in:an:ar6a of, environmental concern pursuant to 15A NCA
:E] RUlds4ttacKed.
Applicant Name
Project Location: County '&�,4L4
Address
---L,4z-y ?,414t I Street Address/ State Road/ Lot #(s) 0-F F
-Y 90 -z. -
Statef4',_ ZIP - L A 1-4 e
City-
Phone' Z57' E-Mail' Subdivision -A-a,,r,)
Authorized Agent -_0 -!:Z I L4 T-1 City --Fz -4 ZIP'*
[�J Cw, D EW XIPTA D PTS,, Phone# River Basin-rA.-I-2-t04m"I i �--6
Affected:,, .' -
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Aigent,or Aoplicfint Printed Name
'.Signature Please fea'd compliance statement on back of permii
1 3-
3,9
-ADDlicat - idn Fp , e Che&#
(s)
Perm' fcer's Printed Name
J161 ML
Issbing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in County.
1 furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
- le �gnature
Print or Type Name
ob�-X-.cr
Title
/ Zr' / IT'
Date
This certification is valid through I I

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to i Ait,> �. Y �� . 's
(Name of Property Owner)
property located at j 7 61zy-
(Address, Lot, Block, Road, etc.)
on 73,:.Lyv_V: s e z671e !c in Get;
(Waterbody) (City/Town andlo County)
The applicant has described to me, as shown below, the development proposed at the above
to c Lion.
I have no objection to this proposal.
I have objections to this proposal.
DESC_RIPTION_AN_WOR DRAWING OF PROPOSED DE_VELOPMEN_T
'(Individual propoaing_development must rill in description _below or attach. a_ site_dravling)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, M or groin
must be set back 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 da not wish to waive the 15' setback requirement.
(Prop,qrty Owner Information)
Signature
- — A
Print or Type Name
lei A —
Mailing Addre
Citya/Zip7-0
Telephone Number/ email addres
Data /
Adjacent Property Owner Information)
Srgnatw-e*
`t >~ 7 C_ xx&rnect5�
Print or Type Name
/ oZ7 Pfi.
Mailing Address
City/Stateop
3 3,-" - -3 Soi
Telepho eNumber/emailaddrass
- d* 8'
Dad* -'r
'Valid for one calendar year after signature'
(Revised Aug. 2014)

Applicant:
Date: ) Ar-14 6 to S's 2 -� t
General Permit #: --1 -Z pj �6�
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat flame
DISTURB TYPE
Choose One
TOTAL Sq. Ft
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet -
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
DQ�
.�- q—
Dredge ❑ Fill ❑ Both ❑ Other
LI-q-
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑