Faust, Sara

❑CAMA / ❑ DREDGE & FILL / '' No. 75714
GENERAL PERMIT Previous permit# A BC1 D
4ew 'EModification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality _% 1/
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC / /
❑ Ru/1e's attached.
Applicant Name ' Project Location: County <" j' i
Address
)
City
% i
State
ZIP
Phone #4`)`��Mail
/
Authorized Agent
❑.CW
SEW ❑PTA ❑ES
❑PTS
Affected
AEC(s): DOEA
❑HHF ❑IH ❑UBA
❑N/A
❑ PWS:
UKW: yes / no rNA yes i no
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ ftiprap length_
avg distance offshore
max distance offshore
Basin, channel
Boat ramp,
Boathouse/
Beach Bulldozing
Other
Shoreline Length
SAM notsure yes no
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature °# Please read compliance
Application Feels)
Street Address/ State Road_ / Lot #(s)—
Subdivision
ZIP
Phone # () River Basin
Adj. Wtr. Body (real man
Clncest Mai. Wtn Bodv /
(Scale: /V S )
❑See note on back regarding River Basin rules.
Permit Officer's Printed Name
back of permit" Signature �
Check# Issuing Date,'

AGENT AUTHORIZATION FOR CAMA PERMIT, APPLICATION
Name of Property Owner Requesting Permit: Ear. sl IPL?Pt L U'' &
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
`11
:. rCLU-4
Z7S11
Co"t Z. - L{90%
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
AECA-ib U'J be, 4tjrr'ICcN. YInrOLi°2�
at my property located at %Z3 S na e� 3�t Vy
in Q r}g i County.
I 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:
G Vc L .
Signature
Print or or Type Name
Title
_L/ Z, / Zdlol
Date
This certification is valid through

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at °� 3 S7 l
f
ie of
I
(Address, Lot, Slock, Road, etc.)
on StiAtfl ,in c- ter v N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
lory I have no objection to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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)
CT
Signatureµv 7' /tl, cTooy D?
Print or Type Name,
�z1 sT24t7s
Mailin Address
Fr1, t Lj
City/statelzip
.25-z-Sof-260�
Telephone Number
%-/,-q
Date
(Revised 611812012)

Hurricane Florence and TS Michael
Replacement/Repair Request Form
Date of Request: 9u 19
Sane" raw ai 'Qo A I •%..
Property Owner Name: R-010e i4 C F Cws�
Address of Property: [v
Telephone Number: (rjn) (OZ, — Lt`107 —
Type of Work:
NOTE:
• The Emergency CAMA General Permit 2500 is for repairs and replacement of water -
dependent structures damaged because of Hurricane Florence and/or TS Michael. The
replacement, reconstruction and maintenance excavation activities shall conform to
current standards and rules. All work under the Emergency CA1VIA GP 2500 must be
made in the same footprint of the previous structure with no additions, expansions, or
enlargements.
• If any portion of a structure being replaced is within the 15' setback of the riparian line or
access area, signatures of the adjacent riparian property owner(s) must be obtained
acknowledging the notification and waiver of the setback on the forms provided by
DCM.
• Any mamtenance excavation or dredging requires signatures of the adjacent riparian
property owner(s) on the notification forms provided by DCM.
Signature: Q r/ t & 1fCL-�

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at
m
(Waterbody)
(Name of Property Owner)
(Address, Lot, Block, Road, etc.)
- , in -- --
(City/Town and/or County)
I
N.C.
The applicant has described to me, as shown below, the development proposed at the above
lopatjgr- L' I have no objection to this proposal.
I haw e objQctons_to this.pr_oposaL
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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.)
dUu� I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Ls O.L., skSignature
Pop�P IIL,� �«G�.�—
P!r-int or TXXpe Namff e j
MailingAddres$,,, _
i
bA
Telepho e Numb
T.
Date
�--
(Revised 611812012)