Brooks, Michael Scott

®qCAMA/ C DREDGE & FILL lit t \( ( NO. 73917 A B
GENERAL PERMIT Previous permit#
❑jNew ❑Modification ❑Complete Reissue. IilF`6 ial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environrn&tal Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
/ ❑ Rules attached.
Applicant Name II(� Project Location: County.. _
Address �, %1 i ? Street Address/ State Road/ Lot #(s)
City
Phone #
Authorized Agent
Affected )li Cw
AEC(s): M OEA
❑ PWS
ORW: yes / no
)qEW `` IPTA
❑ HHF n IH
PNA es / no
:e I k-/( ZIP
❑ ES ❑ PTS
❑ UBA ❑ N/A
Phone # (')
Adj. Wtr. Body /
Closest Maj. Wtr. B6d
ZIP
1 River Basin
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Fixed Platform
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Finger pier(s) ISIMME
Groin length A
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Agent or Applicant Printed Name
Signature **Plelaseread compliance statement on back of permit"
7 /
Application Fee(s) Check #
Permit Officer's Printed Name
Signature I
piration Date

AGENT AUTHORIZATION FOR LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: rr I�� c � a V-1 e o Y IYOC <5
Mailing Address: Z' + U I b b 5 Ur
i3 la
Phone Number: -L ti Z 2- H I - Iq Y, 12.)
Email Address: �y u o k S >v� S cW bxo � vv\ a + cc) vv-
certify that I have authorized A r J Y t Wo b b ,
Agent i Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development-.
(A V^
t-
at my property,. V. located at Z 1 U + 5 �-o (1 . Gil to Y C-
in C-()-VAe-re-t County.
1 furthermore certify that t am sulhonzed 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 W4M evaluating information related to this
Permit application.
Property Ownw IMotmation:
1 L&ks
signaturn
I C- k c,-P ( Scot IRV JW ks
Ptint or Type Nance
TNe
03 ,Uri , 7d19
Date
This certification Is valid through I 1
�3/ / �//? ��—

A JACENT RIPARIAN PROPERTY OWNER cT4TEMME
I hereby certify that I own property adjacent fo /f411Cl10 Sc+>Tf 5 s
(Name of Property Owner)
property located at 21 / 616135,
(Address, Lot, Block, Road, etc.) !%if GtfFK in N.C.
on 6!T�faL,<o/Li
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locating.
S I 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)
�I 'VoUc Ir' exis1ir6 /br
foot 12911-T
r2T
lzw61
"-'(4 .. Pa;OWn
-paU/
70 /0 6,0r61,R r
754,o7' 6/47"
�lyfD flo�K
R 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.)
ro /l do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
Liter: Eft
Signuiure Signatr^re'
�i PnClype
nf a T}y'pe Name Print or Type Name
Z6/RSf .y/� �90� Ga/✓Toruo DPiu�
Marling Address , Mailing Address
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Ci /Slate/Lp 1[ J,, City/slatemp
2 2g Or " $ t. lrl4hu,114'k 2Sz
Telephone Number/e rail addross Telephone Number/emairaddress
3-/d-/9 9
Dore /Date
'Valid for one ealendar year after signature' (Revisod Aug. 2014)

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