Smith, Keith

JCAMA'/ El DREDGE &FILL ( ( YIYr No. 75252
�i A B C D
GENERAL PERMIT Previous permit#
L,New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission 'n an area of nvironmental concern pursuant to 15A NCAC / OR uI
/) tj^ ley attached.
Applicant Name I \ r I '-, C I I � '-J � Project Location: County C . r> l t'',
City ) c- /' 'I i "t
Phone # (
Authorized Agent Z
4
d "6W CAW ❑PTA
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Affected `
Affecte 71 OEA ❑ HHF ❑ IH
❑ PWS:
Street Address/ State Road/ Lot #(;) /
State/" ( ZIP e
ORW: yes /�'no PNA yes ('no
Type of Project/ Activity
Pier
Fixe
Float
Fing
Groi
Bulk
Basi
Boat
Boat
Shor
SAVE
Mor,
Phot
Waiv
Subdivision..
city � �f � I ZIP
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LIES ❑PTS Phone# O [Rivervg/asin
Adj. Wtr. Body
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Closest Mal. Wtr. Body
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(Scale: 'XV%j )
Ing Platform(s)
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A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
.-2 "s^+_
r
Signature ra Please read compliance statement on back of permit
Application Fee(s) Check #
❑ See note on back regarding River Basin rules.
�(ed Name
Signature;
Issuing Date f Vpiration lbate

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: iTE: Z '5 � ; f 4
Mailing Address: / 746 /, /; /(! %r
Phone Number: `2 7 L 7�5�
Email Address:
I certify that I have authorized ��-7 Z S ,
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
-f
at my property located at _ ems �, l�rE z �� r .f/C' ,
in County.
I furthermore certify that l 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:
Signature
Print or Type Name
c-- r
Title
Date RECEIVED
�y AUG 1 4 2019
This certification is valid through _ Q_11 1 �d DCAU
MHD CITY

Hurricane Florence and TS bfichael
Replacement/Repair Request Form
Date of Request:
Property Owner Name:
Address of Property:
Telephone Number: //9 2 % K 295-4�
Type of Work: AJICI ,'Y plvc le
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 CAMA 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 maintenance excavation or dredging requires signatures of the adjacent riparian
property owner(s) on the notification forms provided by DCM.
Signature:
RECEIVED
AUG 14 2019
DCM-MHD CITY

IV