Trevino, Ray

®CAMA / ❑DREDGE & FILL I �( �` L` ;�
... (�: � (,� No. 75007
NERAL PERMIT Previouspermit #
ew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous p ri
As authorized by the State of North Carolina, Department of Environmental Quality 7.
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC_
Applicant ami el � al ( 'i C A i . / Project Location: County
Address \ I, f s (� ) Street Address/ State Road/ Lot #(s)
city r,, -�\.�1 �*U.(• ` - --State I _ / ZIP
Phone # () I
�, �1.E-4-1I
Authorized Agent
OCW
DEW ]PTA FIIES ❑PTS
Affected
❑OEA
AEC(s):
❑HHF LJIH i-1 UBA El N/A
❑ PWS:
ORW: yes / no
PNA yes / no
A B /C D
Subdivisi n (.
City " !!" �// C ( ZIP Y_�
7 Phone# (� �/ 7� 'vdr Basin j /(
Adj. Wtr. Body 1) i' l �l {.G:� l .(nat /man /unkn)
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Agent or Applicant Printed Name
Signature "Please re'adcompliance statement on back of permit sir
Feels) Check#
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Permit Officers Printed,Name
Signature
Issuing Dat

6Zuv��_
I hereby certify that I own property adjacent to L �l .'< 's
`,gipp (Name of Property Owner)
property located at JJ�G 4—&-dux life.
(Address, Lot, Block, Road, etc.)
on A" C�P� in /�% �iPw�] 4� , N.C.
(Waterbody) (City/Town a d/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 hav_e_objeLtionstothis_pr_oposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
�r
_ 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 wi to waive the 15' setback requirement.
(Prop rty nformation) (Adjacent Property Owner Information)
Y
Sig at Signature
0
Print pe Name Print or T , e Name
Mailing Address
iyl�ef .yc agss
Cit /State i!Z p—k
-jsg - '�'CT- - S-Sef
Telephone Number
�zl — / ii
Dare
Mailing Address ,
r�o.tic, �� , .24- 245-1-7
City/State2ip
Telephone Number
Date
(Revised 611812012)

f
I hereby certify that I own property adjacent to /AA ✓ IIPD 's
(Name of Property Owner)
property located at Z w4&hS A2•
(Address, Lot Block, Road,,etc.)
AJI on 5 ��-���k in 2AAL a 8SS7 N.C.
i9 (Waterbody) (City/ToWrri 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.
Aha_ve obj-eQbQns_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.
do not -wish to waive the 15' setback requirement.
Information) (Adjacen /ejrty Owner
1�1 / 9 ) �
g s-y - Ws- t 7
TiTelephone Number
X -2l - / 51
Date
Telephone Numb r
Co �I Date A
(Revised 611812012)

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