Purcell, Teresa (2)

®^ ❑CAMA / ❑ DREDGE & FILL No. 75045 A B ( C D
GENERAL 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
and the Coastal Reso rces Commission in an area of environmentaj.co cern pursuant to 15A NCAC
1 � i �_ . ; ❑Rules attached.
Applicant Name ! - /�z/-� . :` ! (/ ( Project Location: County
Address ? ` — —y/', Street Acjdress/ State Road/ Lot #(s)
CityState I It ZIP'_
Phone # (___) E-Mail
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A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
i
�1
Agent or Applicant Printed Name
Signature `Please read compliance statement on back of permit"
[� See note on back regarding River Basin rules.
+
Permi[Of(icer's Printed Name
Signature
Application Fee(s) Check# Issuing Date Expiation DIte

1 hereby certify that 1 own property adjacent toC1-12 s
(Name of roperty Owner)
property located at f r,2 7 JLV
(Addreas, L'o—t,`BlockR ,etcc.) �
on in N.C.
(Waterbody) (Ci /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.
- ----[ bane.objectionsAQ this -proposal
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
X 4�
lzt4r�
U 7 r)
-e c D
JUL 0 9 2019
DCM-MHD CITY
_.-__ 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.
/>-�2 fin,/9
Date
Property Owner Information)
or
,%lSIle -.S`l1C- 1-1
Telephone Number
Date
(Revised 611812012)

I hereby certify that I own properly adjacent to _ iX- Q�� s
(Name of Property Owner)
property located at 7 /(Add {'es3, Lot, BtocK, Road, etc
N.C. -
on 31U—) in
(Waterbody) (C (Town and/or County}
The applicant has described to me, as shown below, the development proposed at the above
Iocat n. I have no objection to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
A Od
J
WAIVER SECTION-
- - et
I understand that a pier, dock, mooring pilings, -breakwater, boathouse, lift, or gggir<!me sou
back a minimum distance of 16 from my area of riparian access unless waived by ( Y
wish to waive the setback, you must initial the appropriate blank below.) JUL. 0 9 20t9
I do wish to waive the 15' setback requirement 0CM-MHD CITY
I do not wish to waive the 15' setback requirement.
nt Property Owner Information)
(Progelrty Owner Info lion) ( 1Ad'ace
signature� gpature (tea rn e- v -
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Nly/^uw,c✓uy - LI o� % d�
Telephone Plumber
Dae
ty fele11�hone Numdbr�� 4 cf$K
Date _ 9-e) •.O1 S_ ��) �oi7
(Revised 611 a'2012)

REcFIvCr)
JUL Q 9 ...,,�