Sansone, Peter

w/
®KCAMA / El DREDGE & FILL N2 71671 A B (C' D
GENERAL PERMIT Previous permit#
IlNew ❑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 NCACr ' /-' • / % / ( i
RRules attached.
Applicant Name Project Location: County---,',,
Address Street Address/ State Road/ Lot #(s) C Y
City_ . -_ State ZIP
Phone # ( ) E-Mail Subdivision r /
Authorized Agent
Affected ElCW ❑ EW Q PTA ❑ ES ElPTS
A
Affecte ElOEA ElHHF ElIH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / no PNA yes / no
City_ ZIP
Phone # ( )_ River Basin
Adj. Wtr. Body (nat /man /unknJ
Closest Maj. Wtr. Body
-'■iiii�iiii�iiiiiiiiiiiiiiiiiiii�iiiieiii
•
■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■LIE■■■■■
f
Ea
■■■■■■■■■■■■■■■■■■■■■■■■■■■■rii?I■■■LINE
■B�ENEE■■■LIE■■■■■■ENE■■■■LIE■■■r/Er■1lNI�■\l■
NEE
EE■■■■■LIELIE■■■■■LIE■■■E��■n■■■o,�rufr�u■r�■
■■LIELIELIE■■■■■ELIE■NEEw�►�w��l�■LIE■►■■�■�■��■■
■■■■■■■■■■■■■■■■■LIE■+■■■■■■■n■■■E■E■■■■■■
■■■■■E■■■■■-.i■E■■■■LIE■■LIE■■c►
■■■■■■E■■Ell�l�aEE■�!■Lh��Nuw■■►IL�!�f�■■ME■■E■
■■■■■■■■Ei11 MINA1111ME
• ■■■■■E■■r�■yl�f�N■■■■■■■E■�E■EE�i�I:`!�■LIE■■■LIE
■■■■■■■■��`■■■I�■■■NEE■■E'�■■Er:-:•EE■■■■■LI■
■■■■■■■LIE■LIE■�i■cLIE■■■LIE■�■
■LIE■■■■■■■■EEr.■■■I■Er■■■■_LIE■�
LIE®EE■■■LIE■■■■■■:■■■■■®■■®■■■:■■■■■■■®LIE
■■■EEE■EE■il'llll�illlAl�ilE■■■IR�EEl1■■■■■■■■EEE■■■■
•■■■tL/!!t■EEEEEE■EYI91iE■■■I�Bim11:E1■■
ia�®essisiiiiiii'E���'■�r�iii■uii�::::.:.:
•
tEE■R:I�■■NEE■■
■®■il■EMWEENE■rR■■■■■■■
R■■EEE■■■■■EE
■EEE■■■■■■■
Ii1�■LIE
■
■
�g - r
Agent orApplicalit P/ine d Name
Signature "Please read compliance statement on back of permit"
Application Fee(s) Check #
PermitOfficer's Print d Jame �I

`o
hereby certify that I own property adjacent to t )ti ✓ �0 f 's
(Nan)e of Property Owner)
property located at 05 t
,.� // / (Address, Lot, BloCCc oad, etc.) 2 - p
on l i"�) /r 1e 1'1,y%✓�J6'io- in jVCnV Lft' // ft !S N.C.
(Waterbody) (CitylTown and/or County)
The applica fhas 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.
perty Owner Information)
ature
or ype Name
of (' t,c-%Lr�ss Cl
yA dress r'
eGi✓
5tate1Zi
_;JET-Y���
)hone Num7b7��er mail address
(Adjacent Property Owner Information)
Signature*
Print or Type Name
/, i e 6 C rG A C�
Mailing Address
City/statelZip
Telephone Number/email address
Date*
`Valid for one calendar year after signature*
(Revised Aug. 2014)

I hereby certify that I own property adjacent to
of Property Owner)
property located at
- / (Address, Lot, Block oad, etc.)
on (�e
-t,:71�� %�.✓Oettr— ,in /sic- Zyr 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.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Proper ty7Owner Information) I "-' 10
/E-
Print qr Type N me f�
!9a' 1 "ee e A7' C 2 J ,J
Telephone Number/errvQil address
F/i 4, 6''tw7
Date
rope. ty
rn
GYty/State'17_ J72/�`
TelePho" nee Nurnber / e6fitif address
n)
(Revised Aug. 2014)
`Valid for one calendar year after signature'

-r-
v
4.
m
0
c
0
am
r