Woudstra, Hilco

®NCAMA / O DREDGE & FILL No. 75295 A B C 1' D
GENERAL PERMIT Previous permit#
INNeW ❑Modification ❑Complete Reissue ❑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 i
O Rules attached.
Applicant Name I + Project Location: County \-
Address Li , i / __ Street Address/ State Road/ Lot #(s)
City -
State / !r ZIP
Phone # (_) 'I'- i E-Mail
Authorized Agent
Affected 0CW EIEW OPTA ,.pES ,OPTS
AEC(s): 0EA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / no PNA yes /,nod
Subdivision / �(
City ZIP
Phone# O River Basin
Adj. Wtr. Body t J(nat_./man /unkn)
Closest Maj. Wtr. Body!
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Agent or Applicant Printed Name -
Signature **Please read compliance statement onback ofpermit
•*
Application Fee(s) Check #
PermitO facer s Printed Nanny
Signatu e
Issuing/ Date Expiration Plate

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
Mailing Address:
l07 t��P+t�NUawaE
-I-E ra J E Lo �� tJL 28's3 Z.
I certify that I have authorized (agent) T)eK LE u/ t S to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) Ta "82 —i"-e� our ��"fo rv5 U2t�.t.J�a�-
LC1c��c>K 'Tc� �Tinll+lc
Cz2
at (my property located at) _ i o_7 Do L.Q t't t tl L. t tA;--
This certification is valid thru (date) 711 2 �q
VI
Property Owner Signature Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to U--4�`/'s
4 (Name of Property Owner)
property located at /
(Address, Lot, Block, Road, etc.)
on ��//—Y�S� in /'-//4UC^.CGGeo�: , 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)
d esue, c25 C--,) 1�1 T4"
wA7-1; Z
Z'AAlC)
-17
P/2a /oos .fD _?
C>C/sy--i A/ r]
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.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
yet _e�
Sigilature
/7(/Aro woad S'T/41
Print or Type Name
Mailing Address
yraC�/_ -(oar., . / C z85�
9l?6'7�
Tele hone Number/email address
,(<o e9 1114eo \y-a_2jsYa /s, ccAA
Date3/ 20/�
(Adjacent Property 0,49er Information)
Print
or Type N �
� v <
Mailing yla re1/1 L 1
City/StaVt-e/ZiVp �7- 5-; ' 2
Telephone Number/email a dress
252- -*-�Z/ - tT 3
Dales* P/ 21/
(Revised Aug. 2014)
*Valid for one calendar year after signature*

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to / )af1 A i G/ /V /1 Q'L✓ IC s
(Name of Property Owner)
property located at /O�/�� w 1 aJ
/ (Address, Lot, Block, RoadZ etc.)
on N P 4x e- in /'14yC A) N.C.
(Waterbody) (City/Town and/or County)
The applica 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)
el,<25
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 youwish to waive the setback, you must initial the appropriate blank below.)
r//1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
i nature
,146161
Print or Type Name
Z1 % AC641WItf SCAN/,A
Mailing Address
A/AOC-AAl R8532
city/state/zip
-B&AI ? -,Sw- 06911
Telephone Number/email address
Date
A C Y5 cr7- a3, AgIf
(Adjacent Property.Owner Information)
Signature* y�
Print oType $N
0Z h
�� � mot-- et/
Mailin�dres�
J
Date
709 2->-And-4�06A
/ email address
(Revised Aug. 2014)
*Valid for one calendar year after signature*