Clark, ED

®F14CAMA / ❑ DREDGE & FILL NO. 75043 A B C D
CENERAL PERMIT Previous permit#
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department o"i Erivirronmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
f Rules attached.
Applicant Name
Address l'
City
Phone # (_
Authorized Agent
Affected ElCW VW PTA ❑ES ❑PTS
AEC(s): El OEA ❑ HHF IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / n PNA yes / 60
Type of Project/ Activity ✓1
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision_
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Phone # (�7) � % �/ )� River Basin �..
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not sure yes 11 no
Moratorium: n/a I yes no Photos: yes no
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A building permit may be required by: {. ! } l
( Note Local Planningjurisditton) -
ri 1
Notes/ Special Conditions 1 -f) f.�(l�i (/�
Agent or Applicant Printed
Name
"
Signature Please'read compliance statement on back of permit'°t'
Application Fee(s) Check#
See note on back regarding River Basin rules.
PermitOffcer's Printed fyame f �"
Signature_.—'-}//
I
Issuing Date Expiration to

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 56 C `-+eI<
Mailing Address: 'M ® J r-Alj� f,i G• 5 F,+re 4 t (iz) V417
W 1 L-5 0t'1 / nl C -2--7 F I (�
Phone Number: 1151 - ®
Email Address: �� Lam1Imer -� F_dr'M4rf cDd
I certify that I have authorized
i� Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: D C 'T
bo vt - 11-C4- /�) s4-r)r/( f D e�,
at my property located at I ''
in CA1eTr-C1W?'County.
WCA
(2 1
1 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.
Proeerty Owner Information:
Signature
Print or Type Name
-6LjtJeFP-
Title
6 i -z7 l_
Date
This certification is valid through 1 % 1 31 1) I
RECEIVED
JUL 10 Z019
DCM-MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to JED CL"A-y? KS
property located at 141.,, GAVvi EW 9i7V '
.(Address, Lot, lock, Road, al
on M04 ��/ I -§4A-P D 15fW, in 1—d_4AL11
( aterbody) (City/Town
's
N.C.
The applicant has described to me, as shown below, the development proposed at the above
lootian.
-6-1 I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWINO OF PROPOSED DEVELOPMENT
(Individual proposing development must till In description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp. 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.
-ib► _ 1 do not wish to waive the 15' setback requirement.
(PropertyyOO�w,tneer�IInn formation)
yre 11
(:::(
Pdrrr 'r Type Name
� n
Mail �ddress
City/state2ip
Tele h9 el" m er/email address
Date
'Valid for one calendar year after signature'
(Adjacent Property Owner Information)
rgnnlure
6L-A4R/; RECEIVED
Pnht or Type Name _ _
rJC_ .%7G(6 JUL 1 0 2019
sYta�, ' email address pCM-
MHD CITY
(Revised Aug. 2014)

s Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
'DA-tJ A � Q�t�� ►.1
C, G 7
9590 9402 4768 8344 1540 93
'018 0040 0001 0845 8495
PS Form 3811, July 2015 PSN 7530-02-ODO-9053
❑ Agent
Is delivery address different from Item 17 Lu Yes
If YES, enter delivery address below: ❑ No
Service Type
❑ priority, Mal Expre"
AdultSignature
❑ Registered Ma -
Adult Signature Restricted Delivery
D Registered Mail Restricted
Mal® Certified M®
Delivery
Certified Mal Restricted DeINery
0 Return Ft o Ipt for
colKtt on Delivery
COW on Delivery Restrieted Delivery
Merchandise
D Signature Confrmation-
Insured Mal
D Signature Confirmation
Insured Mail Restricted Delivery
Restricted Delivery
Domestic Return Receipt I
RECEIVED
JUL 10 2019
DCM-MHD CITY

RECENED
30L ] 0 M9
DCM-MHD CITY