Wax, Julia

I / `y
DREDGE & FILL
—�f
No. 74950 /
A B D
�
GONERAL PERMIT
iFrNew
( j
Previous permit#
❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality -�J !� (`
� r�
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC /
/ /
/ ❑RuIesattached.
/ '
Applicant Name
Project Location: County C
Address % / ' -�F
Street Address/ State Road/ Lot #(s)
City State y ZIP �,
r
Phone # O E-Mail
Subdivision
Authorized Agent
City-4 '`', ' ZIP
[ACW ❑EW MPtA El ES ❑PTS �,
Phone# ( ) River Basin
Affected
AEC(s): 00EA ❑ HHF ❑ IH ❑ UBA ❑ N/A
(
Adj. Wtr. Body I �" '- 1 j nat man unkn
❑ PWS
% /
ORW: yes / no PNA yes/f no
Closest Maj. Wt.. Body� 2 1 -V I
Type of Project/ Activity
Pier (dock) length_
Fixed Platform(s) _
Floating Platform(s)
Groin length _
number
Bulkhead/ Ripmp k
avg distance c
max distance
Basin, channel
cubic
Boat ramp
Boathouse/
Beach
Other
Shoreline Length
SAY: 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
r`i I t ( J t,
Signature "Please read compliance statement on back of permit"
Application Fee(s)
(Scale: /<, // )
❑ See note on back regarding River Basin rules.
PermitOffcer's
Signature /
Issuing Expiration Date

Hurricane Florence and TS Michael
Replacement/Repair Request Form
Date of Request:
Property Owner Name: J u1 i ck (� r k
Address of Property:
Telephone Number:
Type of Work:
NOTE:
•
73 oN Soue\A J(- )�-roo-nA ) SJe NG
n
7 3-D - sX6 ci
ena
3 wJw
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: '�—�`�'
RECEIVED
MAY 31 Z019
DCM-MHD CITY

AGENT AUTHORIZATION FOR LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: A+W'K Wax
Mailing Address:
Phone Number:
73 iV So ti A14 Pti
EMeIr.> 4 Qje /&- 28�g
2S2- 2`f/- 9527 Tk11'A V/ax
Email G
Address: D�iC� E t l2EFlLRf 60M
I certify that I have authorized �� i, ri V l 1i
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at mypropertylocated at 73 LV 561.[MCl U C 6/t4'l _TS le i\f
in County.
I furthermore certify that I 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:
Signature
M041- E. WAX
Print or Type Name
� I A)Uy
Title
Date
This certification is valid through