Allen, Rudolf Jr.

Al
17 CAMA / ❑ DREDGE & FILL NO 71625
-". A B C D
GENERAL PERMIT Previous permit#
❑New ❑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 �! / /'
�
/� Rules attached.
Applicant Name t (}� /, ii, Project Location: County
Address /7 �' �F' f'{�Ik f t I l. 1//� Street Address/ State Road/ Lot #(s) IC1% /V
City �211\ilC/ State ly C zip) A.
Phone # E-Mail
Authorized Agent
Affected 0 CW DEW �� FTA ❑ ES ❑ PTS
AEC(s): LJ 0EA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes l(�) PNA yes /(n�)
Subdivision
City Q%e4z p (1) / ZIP
Phone#O River Basin
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Agent or Applicant Printed Name
Signature '• Please read compliance statement on backof peratit
Application Fee(s) Check #
a ' jf ii 11
PermitOffcers Printed Name
r
Si nat re
Iss ingD to ExpirationDate

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: % C, t Q rc 4 al I (e S�
Mailing Address:
C(�
Phone Number:
Email Address:
I certify that I have authorized
e -:) -7-5
I A �-�, Ka; -1 M �Yri f�
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: d 6 C' �—' a -' --J
at my property located at Cr `iVYZ-1
in G-ct Ve-1 County.
1 furthermore certify that 1 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:
Z5�!�:( d,41 O
ignature
d
for Type Name
6jcvvt er
Title
S 1 f ->- / 4L6
Date
This certification is valid through I I

I hereby certify that I own property adjacent to _J� L
property located at DSO' 2 Al C 4 /�-Gr
/1 (Address, Lot, lock, Rpad, etc.)
on ��r- �5 T rl fzdIC4, in tv t' <- ,!C C"? /-I f , N.C.
(Waterbody) (Cityfrown 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)
vw
1,6C)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, reakwater, boa
must be set back a minimum distance of 15' from my area�of riparian acce,,
me. (If you wish to waive the setback, you must initial the appropriate blank
I do wish to waive the 15' setback
I do not wish to waive the 15' setback requ
(Property Owner Information)
city4state2ip
Te ephohe Number/email address
lift, or groin
s waived by
Property Owner Information)
Mailing Address
�LQ .e �',_s' 7
Cd,y/State ip
2 .1, /'
Telephone Numr/bemail address
/
h
Date
Ddre*

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to NA A dt '\ L A ( ( f"I ,:5.--'s
_ (N me of Property Owner)
property located at SC1 iu C-r e,Vr-+', S�-
' ( (Address, Lot, Block, Road, etc.)
on _Ne-(4 SC Ill ) V'✓f in L r W (? � ,, iq �c^ U�,3 , 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)
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 Inf71ZL—
ation) Adjacent Property Owner Information)
g
S,�* nature. nat re
Print or Tylle Name , Prfp�Qr Type Na, !.J-
c -? � 51P-0
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Telephone Number/email address Telephone Number/email address
Date Date* '7110
(Revised Aug. 2014)
*Valid for one calendar year after signature*

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