Raymond, Mat C.

❑CAMA / ❑ DREDGE & FILL ,jai / `- �� r )� NO. 74407 ®GENERAL PERMIT Previous permit# A B C D
❑New ❑Modification ❑Complete Reissue ❑Partial Reissues Date previous permit issued
A.
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
❑ Rues attached
Applicant Name Project Location: County k t r' i (r
Address _
City
StateX ZIP
Phone # (_--)
__E-Mail - w
Authorized Agent
El CW
Ll EW ❑ PTA ❑ ES L1 PTS
Affected
AEC(s): ❑OEA
❑HHF LI IH ❑UBA ❑N/A
❑ PWS:
ORW: yes /.%no
PNA yes / no
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP _ 7_
Phone # (� ii ) River Basin
Adj. Wtr.
Closest Maj. Wtr. Body _ _. _
-(nat /man /unkn
Type of Project/ Activity
7L,
Pier (dock) length
Fixed Platform(s) ■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■■■
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Floating Platform(s) INMEMEW
No
Fingerpier
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Groin length
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number
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Bulkhead/ Riprap length■H■■��■■■■MIMS
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max distance off ore■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■■■■■■■■
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cubic yards
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Boat ramp
Boathouse/ Boatlift ■■■■■■■n■■■®■n■
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Beach Bulldozing— ■■■■■■■■■■■■LI
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Shoreline Len h
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Agent or Applicant Printed Name. -
Signature �`Please read compliance state ent onb ckofper t*'
Application Fee(s) Check #
c /�
PermitOffic 1Printed�tV "`—
Sign t re I
44
Issuing Date Expiration ate
l

AGENT AUTHORIZATION FOR CA.MA PERMIT APPLICATION
Name of Property Owner Requesting Permit: %3 A,4- C /Ze4 /14,04 0
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
�ON t/iN-e4ArAt Aloe-e
0a4KS4Au;000 Ale- a-C s y in
!CC — -7g7 — y/ 0 I
Agent /
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: /^�Lo Da i r 2 X r Sfi % -6
at my property located at / D 0 /,�T ,rA Ia ATCa,a
in County.
I 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:
Print or Typ6 Name
Title
l 2-
Date
This certification is valid through /

AnJACENT RIPARIAN PROPERTY OWNER STATEMENT
certify that I own property adjacent to
ame of Property Owner)
located at
in
etc.)
and/or
N C.
applicant hasflescribed to me, as shown below, the development proposed at the above
I have no objection to this proposal.
I have objectlons to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
erstand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
a minimum distance of 15' from my area of riparian access unless waived by me. (If you
to waive the setback, you must initial the appropriate blank below.)
C y/stat
T1 lephoi
4+.
Dt
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback
Owner Information)
4►ni
- 21.5 8-- Y � 0
Owner Information)
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