Burkot, Jerry

®^ QCAMA / ❑ DREDGE & FILL ' , I y — NO. 74912 A B C D
91ENERAL PERMIT Previous permit#
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality' 1
and the Coastal Resources Commission in an area of a vironme tal concern pursuant to 15A NCAC /
1 ) _ /• Ru%es attached. ;
Applicant Name J .� I 1 1 �, ' � Project Location: County )) 4-i ( �
Address _) t - - 1 l ' l 1V ( Street Address/ State Road/ Lot #(s)
City State ZIP
Phone # ( _') ( ?'" E-Mail
Authorized Agent
Affected CW oEW S TA ❑ES ❑PTS
AEC(s): El OEA ❑ HHF ❑ H ❑ UBA ❑ WA
i PWS:
rf
ORW:. yes;/ no PNA yes /!no
Type of Project/ Activity.
Pier (dock) length_
Fixed Platform(s)
Floating Platform(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshore_
max distance offshore_
Basin, channel
cubic
Boat ramp .
Boathouse/
Beach
Other
Shoreline Length I
SAM notsure yes no -
Moratorium: n/a yes no -.
Photos: yes no
Waiver Attached: yes no
A building permit may be required by:
( Note Local Planning Jurisdiction) \
Notes/ Special Conditions
Agent or Applicant Printed Name
signature .+ Please read compliance statement on back of permit
Application Feels) Check#
Subdivision
City -- _ _ ZIP �.
Phone# (_) River Basin
Adj. Wtr. Body _. ; (nat /man /unkn)
Closest Maj. Wtr. Body
i
i
(Scale: )
C ❑ See note on back regarding River Basin rules.
i
Pet mltOff lcer's Printed Name
i
Signature
Issuing Date Expiration ate

Hurricane Florence and TS Michael
Replacement/Repair Request Form
Date of Request:
Property Owner Name:
Address of Property:
Telephone Number: f
Type of Work:
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:
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT Z5 a. - 670 — o y 3 i
Thereby certify that I own property adjacent to re f` i r 's
(N npe of Property Qwner)
property located at _j ( ice. (�.�L (�c 1 �� r ��l �
I (Address, L t Block, Road; )
on K\U,< <,—.__� , in s , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
Iocat'6n.
J I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must rill in description below or attach a site drawing)
L,k(
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Kd �
,710 rzeA),e w6dtb br,
7�2POT W cve Ds AIL 2-g6 e, 2� - L 7z,�--
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.) RECEIVED
%do wish to waive the 15' setback requirement.
. JUN 06 Z019
I do not wish to waive the 15' setback requirement.
Information)
,
Agd&ure P
Print or Type Name
Meiling,
City/State/Zip
Telephone Numq er
6- a -lz)
Date
(Adjat Property Ownr information)
Signature
b A ,/ L . (` oyzt 1
Print or Type A(ame
/7S L((/
Mailii Address
7 /�/_�� r%r'�S/
c6V,$tate/zip
Z2-�/S-zjJ%
Telephone Number
--a do/S
Date
ITY
(Revised 611812012)