Brown, Robert

N
'4CAMA / ❑ DREDGE & FILL
No. 73373 A
B (C D
GR ENEAL 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
_�
106,
and the'Eoastal Resources Com
ission in an area of environmental concern pursuant
to 15A NCAC
�/
/
��pReesattached.
�/ �
Applicant Name
. , ; J(��/ _I'.%
Project Location:
County
Address 1;� ) f'< f t > , l /�
Street Address/ State Road/ Lo #(s)
City_ fi
r�ll� State Al `ZIP ?� ) I l
i.-,/ .
�f'rf v
Phone # (. ) ?� ' E-Mail
__Icy
Subdivision
Authorized Agent i� ! 4 r' e7
+
City l /
`' / ' ZIP
/
Affected L1CW SEW ❑PTA ❑ES ❑PTS
Phone# ( )
River Basin
❑OEA ❑HHF ❑IH ❑UBA ❑N/A
AEC(s):
Adj. Wtr. Body
_ r !(
nat man unkn
ORW:yes J no PNA yes ( nod
.
Closest Maj. Wt„
Body-
i
-
Type of Project/ Activity /(-
Y t
Pier (dock) length_
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
number
avg alstance i
max distance
Basin, channel
cubic yards_
Boat ramp
Boathouse/ Boatlifl
Beach Bulldozing_
Other
Shoreline Length _
SAV: not sure yes n�
Moratorium: n/a yes 'no
Photos: yes nd _
Waiver Attached: yes no
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions i fj
Agent or Applicant Printed Name
;fgnatuIFre ** Please read compliance statement on back of y*/*�
VApplication Fee(s) 6ecc ,4
❑ See note on back
(Scale:
arding River Basin rules.
4,�,. /
Permit Offic s rn d Name ^_
Signature
Issuing Date Exkatioh Da e

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date��
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent) to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date)
Property Owner Signature
Date
RECEIVED
DEC 2 7 ' 01'-
DCM-MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to zye: \t"
property located at
(� (Address,
\ on 7`e
(Waterbodyj�—
of Property Owner)
etc.)
own and/or County)
I
N.C.
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 ohjectioms to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a `site drawing)
�ti x\<Se�.�. \� ��CSg�jr cXc-
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.
,- erty qmnWe Information)
1
St,kgjn�ature \\
P int or T e ame ailing Ad ress
� N ACC
C /StatelZip
�yo
Telephone Number
Date
(Adjacent Property Owner Information)
A
(Revised 6/1, 010
OGM

n-
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to a\&-' �'s
C t (Name of Proper Owner)
property located at
on
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
x I have no objection to this proposal.
I have objections_ tothis_proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach apsite drawing)
YYNIVCR QcV I IVIY ., 11
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.)
"are
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Adjacent Property Owner Information)
"are
0%
(Revised 6118L26b�
OG