HomeMy WebLinkAboutKilgore, John-.�' CAMA / ❑ DREDGE & FILL No. 75221 A B C D
_IENERAL PERMIT Previous permit#
SfNew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
' j j ❑ Rules attached.
Applicant Name. �(Jt I f ` aC? r r F Project Location: County `/ !♦ c `— s _
Address t`a e� 6 Street Address/ State Road/ Lot #(s)_ `
City L StateA/C ZIP;TP)
Phone # (170 v �' t E-Mail Subdivision__
Authorized Agent City �e��rc" `�{� Zip C�
Affected ElCW PEW i]PTA [I ES ❑PTS Phone# O River Basin r
AEC(s): El OEA ❑ HHF J iH ❑ UBA ❑ WA Adj. Wtr. Body (nat /man /unkn)
❑ PWS:
ORW: /(esyno PIMA yes / no Closest Maj. Wtr. Body
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Agent or Applicant Printed Name
Signature
, dA ,-,r9O,-
"Please read compliance statement on back of permit" Signature'_
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Application Feels) Check# Issuing
AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address: S2 C t P) t)y-e S-�.:nc' O r a
Phone Number: 11 9 D.
Email Address: k 1 gc.re "Z cc, (e-. /� b,M
certify that I have authorized _LZ l�or4c So1� iivr�S % I�au c& �i� c•�5��
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 Ski oc�r-t.
at my property located at Si_i�tn k,Cg }� S� u l�r- CYO r7�\ ci Mx- Z S9�-A
in COX �U'CCounty.
l 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
Print or pe Name
owner
Title
Date
This certification is valid through / /
CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: �ohn
Address of Property: —S20fv §0�uc $o.,ir V9- Dr,vC CMcrgtci 1SIc 2gS9`-i
(Lot or Street #, Street or Road. City 8 County)
Agent's Name #: Mailing Address:
Agent's phone #:
I hereby Certify that I own property adjacent to the above referenced property. The individual
I,ppfying for this permit has described
to me as shown on the attached drawing the development they are roposing. A description or dMwina 'rh dimen r
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must be Provided with this letter.
G I have
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no objections to this proposal 1 have objections to this proposal.
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Ifyou have objections to what is being proposer!, youmustnotNy the Division of Coastal Management
(OCMj in writing within 10 days of receipt of this
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notice. Contact Information for oCM offices is av
all ableathfto:/Avww nccoastainianaoementnet/web/cm/staB Ilsdnp or by calling 1.8884RCOAST.
No response Is considered the same
as no obfecdon If you have been notified by Certified Mail
'
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WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift must
be set back a minimum distance of 15' from
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my area of riparian access unless waived by me. (If
you wish to waive the setback, you must Initial the appropriate blank below.)
X
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I do wish to waive the 15'setback requirement.
I do not wish to waive the 15' setback requirement.
(Prpperty Owner Information)
Signature
Print or TY-0 Nom
f.
Mailing Addres
��"��� Isli Nc zgs9y
City/Srate2lp
15a �41.119z(�tii ofe 2�ec.rr.ra,..\
Telephone Number/Email ddress
f3t,Ity
Da/e
Gregory£. Murphy, MD, PACs
Pms N. Eastern UrologlcelAssociales, PA
Cher awsien of Umlogy
Affiliate Pm/essor a Surgery
Eesl Carolina SPieel a/Medtine
( rian Pr party n)
!f re O r Informatio
�'�' fr�Oor�ry
Print or Typa Name
Marli tldrass
a 2- 324 -zygi ,
Telephone Number/Emailga ss
Uafe
(Revised Aug. 2014)
CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: kA�t r-e
Address of Property: SZ-0 o 30gvfSOvr\& or-'ki eyvLercilc( hlC ZMiIiy
(Lot or Stree #, Street or Road, City 8 County)
Agent's Name #: Mailing Address:
Agent's phone #:
I hereby certify that I own property adjacent to the above referenced property. The individual
for this
applying permit has described to me as shown on the attached drawing the development
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they are proposing. A description or drawing, with dimensions must be Provided with this letter.
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I have no objections to this proposal. I have objections to this proposal.
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if you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days
r
of receipt of this notice. Contact Information for DCM offices is
r
available at http:Owww.nccoastaimanaaement.ttetAveb/cm/staff-iist/nn or by calling 1-888.4RCOAST.
No response is considered the same as no ob)ectfon if you have been notified by Certified Mail
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WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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.)
0 i
1 do wish to waive the 15' setback requirement.
a
�a"
N I do not wish to waive the 15' setback requirement.
t�
(Property Owner Information) (Riparian Property Owner Information)
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Signature Signature
J�l�t, K�t�-t,�e /-Grey � it ay
Pdnt or Type` Nam Print or Type Name
/ /� Q led
izoin &,Qt!e �iivrl( �1-. 7401 /::1-c N'f oo le
Mailing Address' Mailing Address
fcVy, x-aAxl 1 c 1,c , W c. 21� C ri q r g 1 e, .S (t, lik R ws
City/Stata/Zfp City/State/Zip
WSJ41 11ui��,iklrtore.2( tC.rr.rpn 3/96Zf Z83h /a..ryPgy�� Srwbi�.Co�+/
Telephone Number Email ddress Telephone Number Email Address
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Date Date
(Revised Aug. 2014)
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