Davis, Dexter

A/
E rCAMA / ❑ DREDGE & FILL No 71669 A B � D
GENERAL PERMIT Previous permit#
�IrJew ❑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 mmission in an area of environmental concern pursuant to 15A NCAC Jf !
❑ Rules attached
Applicant Name r er ` �� Ly - 1 Project Location: County
e
t h f Street Address/ S to Road/ Lot # s
Address ICJ) `Jrs; f 1 /( )
r
State:'jJ (�P�i 1:>S ✓� D
Phone # () ' ry -6��E-Mail
Authorized Agent`w�
Affected Ll CW M•EW- 94-I TA ❑ ES ❑ PTS
AEC(s): OOEA ❑ HHF 1711114 ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / no; PNA yes / nc�
Subdivision (Jinx \ /f i '
City 'i 4 s G r- A J ' ZIP �G
Phone # ( ) River Basin : ` A -A
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I 50 Nn M W71 VC GGG
Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit **
O
Application Fee(s) Check #

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to )?rr»J/, [ j 114.Alp1we, v S S : i-
/ kl % (Name of Property Owner) ,]
property located at • t�vv/f lw-.v 7 2 S 076P �1Y I �o,1 •- / .Al.-A.xx �#
/ (Address, Lot, Block, Roqaad, etc.) /
on &rrvL Cp���K ,in ��w lyv� ���•Y�r t .C.
(Watsrbody) (CltylTowq�ounty)
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 prosinevelopment must fill in description below or attach a site drawing)
RECEIVED
AUG 10 2018
DCM-MHD CITY
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.)
Dale
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
eotormanon) / L
�•��,s /vrs1� �lf�vl�1
'Valid for one calendar year after signature'
or 1
i •i
Owner
c. Z-3�;'/
City/State/Zlp
Zs'R 72Y-VS'4s,
Telephone Number/email address
Dale*
(Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to (�j j l / .cY�i✓r, d`* 5 S :'�yrL c
/ �i (Name of Property Owner) .)
property located at &rroy/f5 (�K-��3 2 i 07C P y iy 1�a,) -
(Address, Lot, Block, Rdetc)
Ton in /4--t-//e -e— N.C.
(Waterbody) (CityITown 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.
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)
RECEIVED
AUG 10 2018
CCM-MHD CITY
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.
,mrormationi
Print or Type Name
310 3 u� Q v,o( 'R L ✓ ID lJ
(Adjacent Property Owner Information)
f4�' __.I.�L�t.�
,2rs'3
Telephone Number/email address
Dale*
(Revised Aug. 2014)
*Valid for one calendar year after signature*

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for
//Permit:
ASS,
Mailing address: r/ . W av n i? ,i ,u
GJr/suv, N C A7k4 3
Telephone Number: �Z 9 ny 5--(-, /
I certify that I have authorized % Xt�7� -(agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of 5/ `L 15 /37"-aa Is /I -
at my property located at /�yv��s �✓ r_ P,
This certification is valid through
(Property Owner Information)
Signature
Print or Type Name
Title, co. owner or tru to—s property
Date
�S'2_ 90L4,
Telephone Number
Email Address
(date).
RECEIVED
AUG 10 2018
[ACM -MHO CITY