63369_bulkhead_20181116 (2)

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GENERAL,: PERMIT.,,_ ,
. Precious permit„# Cl,$.D' ,
�Nevv. ❑Modification ❑Complete- Reissue
❑Partial Reissue -'bite- previous permit issued :' ^
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in- an area of environmental concern pursuant to I SA NCAC-
,°
M �n S"Id A—r ',
Q Rules attached:
Applicant Name .WA ,J > 1 r� 1-7L,-t-N V ' 1 ' "
Project"Location: County ✓1 �" �i7 a " fib'
Street Address/State Road/ Lot #(s)
City L&z,vliv4fv-r-oi-1 State0 L ZIP �"� ��� � y 3=
Phone # (? 52)- ci.-�'S'- 3350E-Mail `
Subdivision /act +J r -c'Z
".
`
Authorized'Agent
„.
City ZIP
ln�/��F�•it-1��-yA1
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Affected ❑ CW - , ❑ EW. _MPTA ❑ ES ElPTS
Phone # ( ) River
AEC s , o OEA O HHF ❑ IH ❑ UBA ❑ N/A
Adj. Wtr., Body-T/�/�- ' =ti ut�'Cc(nat ' man /unkn)
ORW: yes no- PNA yes=/ noV
Closest Maj. Wtr. Body
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Agent or Applicant Printed Name
z, f�C ,
. Signature ""Please read compliance statement on back of permit
4
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Application Fee(s) Check#
Pel:mifOfficer's Pr�IVame
Signatur-
e xlu�i;`'l►�� 2y►� "jG
Issuing Date . " Expiration Date • ,

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to s�'s
. (Name of PrIbperty Owner)
property located at
on
as, Lot, Bloch, Road, etc.)
in. R9 a -QA J �� N.C.
(CitkiTown a dlor County)
The applicant has described to me, as shown below, the development proposed at the above
to t!
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION! AND1OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must till in description Below or attach a site drawing)
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.)
l do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Propel Owner Information)(Adjacent Property wrier Information)
m
Sy' ature
Print or Type Name P ''nt or Type ame
Mailing Address M it fr A ress /
UJRsi� iey° �d/V , G, City/StatelZi �- cots
City/Statelzip ,` � Q�� J " ho
iv &Ae k®tJ� 02 c�'7 — h o
Telep one Numbe /email addres�S�� ��� Telep ne Number email address
Date Date
(Revised Aug. 2014)
valid for one calendar year after signature*

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 's
(Name of Pr party O )
property located at r, V-Z
(Add s, Lo Block,Roa , etc
on �' , in
(Waterbody) (CityAtownandlor County)
The applicant has described tome, as shown below, the development proposed at the above
loc do .
ave no objection to this proposal.
I have objections to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(lr dfvidusl,propos n cleveloptrrieret.mcast Sail:,in__�e�crlp0 b_e%®uv::®r ftacia a s®t� dpawing)
VtIAIVER 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.)
I 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)
Av-�'
si J q � G •4
Print ore Name
l -< V 'riie
Mailing A dre s n, C z 7 cc�
ash �►�c /" v4
City/siatelZ'
ZSZ ZL7 Zs�a
Telephone Number/email address
1l-- N-4
Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature*

Applicant: ;4A'2g #4Atz. 59,
Date: to �oy�M13 2v g
General Permit #." 7Z /pq
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet. .
TOTAL Sq. Ft
FINAL Sq. Ft
TOTAL Feet
FINAL Feet '
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
Habitat Marne
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and%r
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temli impacts)
amount
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