63367_platform_20181115

_A 11 DRED FILL, GE & No., 7292,
A F" JC 'D,
:CC^MA ),, I f.\ I
P E RM IT Previous permit i
-ElModification C'o- mplete Keiisue, E]Partia]'Reis§ue Date previous permit.issued
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As authorised by,the State 6f North Carolina, Department of EhVircinniental Quality . . . _-� . I
and the Coastal Resources Commission in'an'area of enviroriniental'concern pursuant to 15A NCAC . 0 1 .
F-7.1,Rules attached.
Applicant Name Project Location: County J-2 L-A-41:`teV­ 'T- Z
Address 17 -19
City f 'u u L, L State NL­ZIP 2--) iSS cP
Phone # ElMail
e-dAgent AuthoHz
Affected
EICW SEW �]PTA DES 'D PTS
AEC(s): El -1 N/AoEA 0 HHF DIH EWC❑BA
11 PWS:
qRW: yes /(9D PNA yes
Street Address/'State Road/ Lot #(S') S-?- t
Subdivision
city ZIP
Phone# River Basih 'Ffla'- &'A x/1 Ne'
Adj. Wtr. Body Y1 Ai-) -r-nr�%G: (n Junkn)
Closest Maj. Wtr. Body
M.
M.
- ■■■ii■■■iiii■i�C■■ii■iii�Cii■iiiei�iiiii
/JFA1,1.A zt4nve'
�entor Applicant Printed Name
Signature '"Please read compliance statement on back of permit"
Application Fee(s) Check#
J 2
PermitOfficer's Printed Name
Signature.
-2.c->) f
Issuing Date Expiration Date
Ci

M
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �, a°�_('/�� is
(Name of Property Owner)
property located at �� r` r aq/
(Address, Lot, Block, Road, etc.)
on fc�e `6_"1 14._ 6}410 r' , in � G � , N.C.
(Waterbody) (City/Town and/o County)
The applicant has described to me, as shown below, the development proposed at the above
location.
1 have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
�r
G/
/°ffWt& OesC l�
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be sit
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 do not wish to waive the 15' setback requirement. J'
(Pr pert�(
y Owner Information) Adjacen Trope O er Information)
L i ature _S1/1
Print or Type Name Print or Tye Name
,� ,1-z x �a, leg 02�
Maim Address Ma tin Address
City/State tp City/State/Zip
2 f_2 - 2r 7s'17 cF / ZS - '7,s� /Sm %
Telephone Number Telephone Number
I/ - �-_ P // / /.zz / �?
Date Date
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OlNNER STATEMENT
1 hereby certify that I own properly adjacent to t s s � ��F is
II // (Name of Property Oe�rner). .
property located at /�f
�` rson 1� i/�
N.C. -_I.
(Waterbody) (City/Town andlof County)
The applicant has described to me, as shown below, the development proposed at _the above
location.
._� I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT,
nn�ividuai proposing developmeng must 11H in description below or agacih a site drawing)
WANCR SEC ION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, 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.)
1 do wish to waive the 15' setback requirement.
I do not Wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
Signature Signatures
Print or T pe`� ZL
/y�Print or Type Nam ed/Z� N��_� /JOc /i 31J�(s•�{��
Maili g Address Mailing Address
City/St4a0 City/StatelZip
Telephone ,Number/ email address Telephone Number/ email address
Date Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature*

Authorized Agent Consent Agreement
I des e&gty Z ,& ,hereby authorize 4���, �/(�m�N to act on
(Property Owner) (Authorized Agent)
my behalf in obtaining CAMA permits for the location listed below. This agency
authorization is limited to the specific activities described above.
Property Address:
-2. 7 ez 7
'Property Owner's.Mailing Address and Phone Number:
—2 7 zer /
r2 -
-717- S�'��
Property Owner's Signature:
411�,,
Authorized Agent Signature:
Date: / l —6:26f ZF
Form: Authorized Agent Agreement as developed by NCDCM revised 7/29/09

Applicant: L o13 W o0'rF4
Date: /$ 4 oV F&1 f j 6 s2 Z o I$
General Permit* 7 Z 9 Z * _
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 Name
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%r
temp impact
amount
b�EtJ
Dredge ❑ Fill ❑ Both ❑ Other ❑
2
Z oo 1=
2
ZOO r F
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ - FA ❑ - 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 ❑