Nowacek, Doug

� El / DREDGE & FILL � � (����V�;G,' ! (� (�'� No. 74474 A B C D
���lew
NERAL PERMIT Previous permit#
❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authed by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area ofenvironmental 7cern pursuant to I SA NCAC
I � ❑ Rules attached.
Applicant Name i , f ( Project Location: County
Address tStreet Address/ State Road/ Lot #(s)
City� ,�I. (. � �rl State _/' ZIP >
Phone #
Authorized Agent
Affected
El Cw
AEC(s):
710EA
❑ PWS
ORW:
yes / no
❑EW ❑
❑ HHF ❑
PNA yes / n6
El ES! ❑PTS
❑UBA ❑N/A
Subdivision
City (i .; j ` :. ZIP _
Phone # (_ ) / f / River Basin
Adj. Wtr. Body (nat /man /unkn)
Closest Maj. Wtr. Body
Type of Project/ Activity
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Agent or Applicant Printed Name
Signature Plea a read compliance statement on ba of permit*t'
Application Fee(s) / Check#

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: �� \VO h CPI
Mailing Address:
Phone Number:
Email Address: /
I certify that I have authorized I QK=-4 Y M"C-TA ,
Agent /agYtractcr—I
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 1 ,
in r County.
1 furthermore certify that 1 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:
Sign ture
Prinl or Type Alame
Title
Date
RECEIVED
This certification is valid through I I MAY 0 6 ZM9
DCM-MHD CITY

I hereby certify that I own property adjacent to aV W 1 Ucc. - .'s
(N r f roperty Owner)
property located at 8L
nn 11 p (Address, Lot, Block, Road, a c.
on \v�� I \�4 in N.
(Waterbody) (City/Town and/or C unty)
The applicant has described to me, as shown below, the development proposed at the above
location.
x 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.)
1 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)
St ature Sig atur
�w
Print or 7qV Name Print or e Name I
Mailing Address M ' ng Addrep
City/State/Zip City/Stajwlip D
Telephone Number Telephone Number
Date Date A�.
eH® G\TY
(Revised

ADJACENT RIPARIAN PROPERTY OWNER STATE\MENT
• I hereby certify that I own property adjacent to vP\A, , 's
- 4(Na�ESO%—r!erty Owner)
property located at V'O
(Address, Lot, Bi4ck, Roo , et
on yov ft, 2lye'v in QJNO N N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
x I have no objection to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing devefopment' must ill in description below or attach a site drawing)
rrMry Gm V w I rvl.
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.
x
Telephone Number
Date
(Adjacent Property Owner
InInformation)
v,
Sigg�nature
X Keu S (nI _.n-Fosl
Print or Type Name
Nr-1 ' is-,
MAY 0 6 Z0
(Revised 6/16(2
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