Coats, Glenn R. II

® +❑CAMA / ❑DREDGE &FILL 1 i� \.� � �", (No. 74480
GENERAL PERMIT Previous permit#
w ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authoriz d by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources commission in an area of environmental coot r _pursuant to I SA NCAC '
❑ Rules attached.
Applicant Name Project Location: County
Address ks ' Street Address/ State Road/ Lot #(s)
City State � '1���/
Phone # ( _I)
Authorized Agent
Affected ��cw
AEC(s): ❑ OEA
ORW: lyes / no PNA
Type of Project/ Activity_
Pier
Fixe
Float
Fing
Groill
Bulk
Basin
Boat
Boat
Beac
Oth
Sher
SAv:
Mo
Phot
Wan,
PTA ❑ ES ❑ PTS
IH ❑UBA ❑N/A
yes / no
a_ City r' A/ — L. .
Phone
Adj. Wtr. Body
Closest Maj. Wtr. Body
—ZIP
fiver Basin '
(nat /man /unkn)
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A bui ing permit may a requi a y:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature *Please,rgad compliance statement on back of permit
Applicaiortfee(s) i Check#
__ -. ;f y.
Permlt0f(Icer's Pfinled Name s"-"
Signature ---
Issuing �at��Expiration DateExpiraticn Date

AGENT AUTHORIZATION FOR CAIIIIA PERMIT APPLICATION
Name of Property Owner Requesting Permit: �/eOn �• ��:n� l�
Mailing Address: 37,R`9 -Swim &-vv v a
&Pe�.0 /vi`. ;�753`1
Phone Number: -(, 6 —� -t) t1= S
Email Address: PP tvm
I certify that I have authorized Herber Contracting Inc
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:
at my property located at 3qS t�P2r-5),,a Lr,• (0 Netc'PA^t 255 761
in 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:
Signature
C
Print or Type Name
Title
a I;1 1 12
Date
This certification is valid through 12 1 31 1 19

YC�ef�.R
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to it'J fr t R. Ct%g.J s
friiiitt4 of Prowty Owe"r)
pro;ly Eoo.a° led tat ��� {•� t {f!� �`t ('C.iP
i,r�- (A:i Wen, ! ot, R, Road, ebc )
on i i �GY t .. / P N.C.
(Waterbody) in (CityFrrown arKtlor County)
The applicant has described to me, as shown below, the development proposed at the above
I have no objeetim to this prod.
j
1 have objections to this proposal.
e e
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(Indiyldual proposing developmient must fill In description below or attach a site drawing)
e ,
i
WAiti.+,E,A.
I Understand that a pier, t�C��t, i i^vt) aifi Hlinus S np, breakwater, boathouse, , ^ L n
must be set back a minimum distance of iS from my area of riparian access unless waived by
me. (if you wish to waive the setbaa, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
do not wish to waive the IS' setback retwulrement•
(property dwner Infomiation)
'valid for one calendar year after signature'
Information)
(RevisedArfg. 2014)
a

ADJACENT RIPARIAN PROPERTY OWNER §TATEMENT y
certify that I own property adjacent to �&*7*7 1 P. COO !S 's
located at�b (Name of Property Owner)
9�Poll:4;4� 4r(C�l° _---
m
N.C.
has described to me, as shown below, the development proposed at the above
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I t nd rstand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
m ist be set back a minimum distance of 15' from my area of riparian access unless waived by
m . ( f you wish to waive the setback, you must Initial the appropriate blank below.)
I do wish to waive the 1V setback requirement. ,1
I do not wish to waive the 15' setback requirement.
Owner Infvraralivn) (Af1 er rPrope Owner Information}
-I VC-
-- r_ �S U
address
(RevisedAug. 2014)
'Valid for one calendar year after signature'

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