Goodwin, Emmett G. Jr.

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J CAMA / ❑DREDGE & FILL f ` I j �; ' ( NO. 75013
®
(. A B C D GENERAL PERMIT Pr a,ouspermit#
-INew ❑Modification ❑Complete Reissue ❑Partial Reissue Date pre us permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental c'oncern pursuant to 15A NCAC
❑ Rules attached.
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Applicant NameProject Location: County
Address __ �. Street Address/ State Road/ Lot #(s)
/S ate !`- ZIP
Phone # ()/ f`�%N
jam
Authorized Agent
Affected ❑CW DEW PTA
AEC(s): ❑ OEA ❑ HHF o IR-
❑ PWs:
ORW: yes / no PNA yes /;
Type of Project/ Activity
Pier
Fixe
Float
Fing
Groi
Bulk
Basil
Boat
Boat
Beac
Oth
Shor
SAM
Mor
Phot
Waiv
❑ES ❑PTS
❑ UBA ❑ N/A
Subdivision
City ZIP
Phone # O River Basin
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Closest Maj. Wtr. Body
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A building permit may be required by: -
(NoteLocalPlanningjurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature ** Please read compliance statement on backof permit**.
Application Fee(s) - Chec #
❑ See note on back regarding River Basin rules.
PermitOffcer's Printed Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMEWT
I hereby cergy that I own Property adjacent to ervtnn �� . C�aadovil t J r s
property located at
-
(Address. 1(Q Pof� 'Na" of Properly Owner)
00
onIva 964 (Address. Lot, r+I k cad. broil N.C.
(Waterbody) (City/Tom andJor County)
The applicant 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 ANWOR DRAWING OF PROPOSED DEVELOPMENT
a site drawing)
drawing)
proposing devefopment mustfill in desonptran ED
WAIVER SEC ION
understathat a pier, dock, mooring pilings, breakwater. boathouse in or groin must be set
nd
back a minimum distance of 15 from my area of riparian access unless waived by me. (If you
wls1vto vfaivo the setback, you must initial the appropriate blank below.)
1 do wish to waive the 15' setback requirement.
1 do not wish to waive the 15 setback requirement.
(Property Owner Information) fAd}ecent Property Owner Infomnatlon)
l" i f �
Pdnt
Dare
(. 29 S'( Z
F,
(RevisedOW012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to eMrr> diE 11 . C-700aW t ll IL • 's
l "� (Name of Property Owner)
property located at a )� Poi-1� tirl V�
(Address, Lot, Block, Road, o
on � O►id —,in fr+lan�a'C CULL , N.C.
(Waterbody) (Citylrown and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
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)
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner
/Information) { I, (Ad)ay(�'@'n P�rro/o arty 1Owney Information)
Signature��/.. SignatureF-Mm
I ail
(_ v2-) V��_-
r/1 c>.f o 1 JC) o f
Telephone Number
Date
(Revised 6/18/2012)