Carolina Design Builders Co Greg Teets

P�CAMA / ❑ DREDGE & FILL ti No. 73381 A B 'c. D
GENERAL PERMIT Previous permit#
mNew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Qualityand the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC `!
$J Rules attached.
Applicant Name I i!Iq j l I CtI Project Location: County j i 1
Address t' `- nX i, Street Address/ State Road/ Lot #(s)
City State ZIP
Phone # VO'' E-Mail Subdivision
Authorized Agent
Affected D CW
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ORW: yes / no PNA yes
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Phone # O River Basin /1/-�
Adj. Wtr. Body"%� i' i�, (nat /man /unkn)
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Agent o Applicants rated Name` _
Signixture ** Please read comp lance s ate tt on backof pe`mit't't'
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Application Fee(s) Check #
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Permit Officer's Prigte jam
Signa
i«,a unora
xoir tion Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to lhtiSE k-m Rerrtein6ww 's
property located at
on Daw,�cm cr'e& in One n) &L- I Vn1h1:r6iC N.C.
(Waterbody) (City/Town 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)
(Cc eV —
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)
rLI
Signature
S- dI Ctk nog DR�_�crt�
Print or Type Nerhe
Mailing Address
Cr i cM-ei 1 , AJC� Z i5-7 j
City/StatelZip
25Z-n1-9S{(ro
Telephone Number
Dale
(Adjacent Property OwnerInformation)
f liG� e /'�
Signature
Print or Type Name
13282-
Mailing Address '
lzt H,// VA 2017/
CityiSta— to P
Telephone Number /
0 20/
Date
(Revised 611812012)

I hereby certify that I own property adjacent to nrfsc km I4e�17 )&V64 crIe� JLL60 s
(Name of Property Own*r)
property located at��1(?E Ncik r+5 Pi Gf G 4nj,1JG 1),64411-tl /L�19 Dx -�5cvl
(Address, Lot, Block, Road tc.}
on 17ckws��1 G eei _ in r ..,, al ,rr f
� All o r;rrn1; , N.C.
(Waterbody) (City/Town 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)
_G f4-jCCM4
ci-,e L
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)
)d
(Adjacent Property Owner Information)
'Revised 611812012)

CAROLINA DESIGN BUILD Hoqq-I - i�
Post Office Box 1116 51 (.qpz' HtA+fem�' *P+
ORIENTAL, NC 28571 -� ceel�lxiI�i-son
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