63367_platform_20181115 (2)

OF
- r, ;®'LAMA / ❑DREDGE &FILL No. 72924.
W,�-Ie�v�-'_E�Modifikation'
G'E"NERAL PERMIT`� Ac` Previous permit`a I�
❑Complete_ Reissue ❑ Partial- Reissue• Date previous permit.issued T-N :1 /
As authorized bythe State of -North Carolina, Department of Environmental Quality `
"t and the Coastal Resources Commission�in an area of envirori•rriental concern pursuant to 15A NCAC O1 t� -
"a . ©RUles attached.,
Applicant Name LJ. ? 6- W Project Location: County • R L-A—+ F= 0-9- T- -
-:;Address' • D - 7�sbx 22 "�- Street Address/.State Road/ Lot #(s)'' ,0V cr
City to v'r I, L State NL ZIP '"L-i 453 o Limit ,
r Phone # (3 I -v92 E=Mail Subdivision �Urz-
.Authorized Agent)-T,_� rl i .H S a ti City ZIP
�4 r
❑ CW SEW +PTA '', ❑ ES ❑ PTS
Affected ❑ OEA ❑ HHF ❑ IH ❑ UBA . ❑ N/A
AEC(s):
❑ PWS•
QRW: yes / no PNA yes / no
Phone # ( ) River Basin T/ 61_K"1 L�l J.
Adi. Wtr.. Bodr Mrkzo
Closest Maj. Wtr. Body
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Agennt or Applicant Printed Name
\ ,/i� F6 /ic/l�at
Signature Please read compliance state/ment on back of permit lot
Application Fee(s) Check #
Permit Officer's Printed Name ,
Signature
Issuing Date Expiration Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 4 a / 5- . 6zz6n Z� 's
(Name of Property Owner)
property located at 3% ./'tee As'ic��- %%/��
4-9.j._ D (Address, Lot, Block, Road, etc.)
on foie `l r.,;n,, 4r C4-,�,t in ,ge 7�v , N.C.
(Waterbody) (City/Town and/o County)
The applicant has described to me, as shown below, the development proposed at the above
location.
f� I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
OndiVdual proposing development must fill in description below or attach a site drawing)
woc 't�*v "'0A '�
WAIVER SECTION f
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be s t
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.
1,
7(Prperty Owner Information)
ignature
Print �orType Name ,
Mai in Address '
)C
City/State rp
2 S-a 7 / -) - -! - F /
Telephone Number
1M
Information)
Print or Tye Name
Maf6ing AddressZ :1 ? K�p
City/State/Zip
a-5-J- �,-S"� /Sm %
Telephone Number
// / /.Z/ / P
(Revised 611812012)

§ ;P,
I—r--
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to l r 's f Z is
�. ►_ _ _ , (Name of Property Ownef). -
property located at
on A91, in
(Waterbody)
The applicant has described to me, as shown below,
location.
I have no objection to this proposal.
I have objections to this proposal.
ock, Road, etc.)
. , 6:'' 1i- co- cult' `7'4- , N.C.
(City/Town andloot County))I
the development proposed at the above
DESCRIPTION ANDlOR DRAWING OF PROPOSED DEVELOPMENT,
pngividual proposing development must fill in description below or attach a site drawing)
!<, - -,2,1,1
lzwef��rp'�f
WAIVER SECTION
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 Signature
A,0 % 5 H 1416,a) a Il
Print or T pe e p / Print or Type Name /
Willing Address Mailing Address
Qty/StateO City/State/Zip
Tel��on�um er/email address Telephone Num er/em/aaddress
T� -
Date F- Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature*

Authorized Agent Consent Agreement
I " des e&gt?,Z Ec& , hereby authorize � �„ �/(�m�/�- 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:
Property Owner's.Mailing Address and Phone Number:
�c•J'r lZj-0
i
Al
d,`
Property Owner's Signature:.4l
Authorized Agent Signature:
Date:
Form: Authorized Agent Agreement as developed by NCDCM revised 7/29/09

Applicant: L. c/S WDoarV4
Date: /5 4o-VE,"0or!L ZDI $
•General Permit M 7 2 9 7-
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
tern impacts)
FINAL Feet '
(Anticipated final
disturbance.
Excludes any
restoration and%r
temp impact
amount
bnEN
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 ❑ FIII ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑