Sutton, Lillie

CAMA / 1 DREDGE & FILL No 71622 A B (CJ D
GENERAL PERMIT Previous permit#
RNeW ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality f t
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC I
/ II ; NJ Rules attached.
L Applicant Name .-1 l ( t [,, A) r;" !2 / Project Location: County 11 "—
1
Address �r� (�, t 1 l W Y �` 4��J ( Street Address/ State Road/ Lot #(s)
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AiG,ZIPr ���1 � �� �Ir^.{!-� (`yL� --'
Phone #
Authorized Agent E ,,wl b ( ,
Affected ❑CW A®EW ,YPTA
AEC(s): El OEA ❑ HHF ❑ IH
❑ PWS:
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A ES 't
❑ UBA ❑ N/A
ORW: yes / no PNA yes [ ho,�
Phone # ( J
Adj. Wtr. Body ' l\ r ` ! V
Closest Maj. Wtr.
F^
Basin
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Agent or Applicant Printed. Nar
Signature****PTeasereadcompliancestatementonbacko�ermit*C**C**
_ � 1ll((00
Application Fee(s) Check #
Permito(ficer s Primed Name !
Signatu e A i
Issuing Dale Expir4fion Date

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St. Jude Childretfs
Research Hospital
Finding nnn. Smirrg Arildmn.

p
I hereby certify that I own property adjacent to 1i 1 111 & ✓Q p/) 's
(Name of Property Owner)
property located at ) AL� 8n ��1 UC r
(Address, Lot, Block Road, etc.)
on �141(� uc� r in Llaft 11C0('D N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location
1 have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF,PROPOSED DEVELOPMENT
(Individual proposing development must fill ini description below or attach a site drawing)
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.
67— 1 do not wish to waive tiie 15' setback requirement.
(Property Owner Information)
Signature Lillie Su or)
Print or Type Name
6 6s : M/
M Ule , NC age 3
City/stat— e/Z�'
r-).5 ,4- & 3'7-G'336)
Tel; hone Number
-/—Ig
Date
(Adjacent Property Owner
Print or Type Name
Mailin6 address r
City/ tate/Zip
aC2-
Telephone N tuber
Fl— j
Date
L fiD, a
I R. t\'m6J
(Revised 611812012)

!�k
� ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to L I l ii� 5u*-On 's
(Name of Property Owner)
property located at :1 ! v �e ✓ Sh a -es �& o L -4k
(Address, Lot, Block Road, c.)
on EY9 �,°C I Ue t— in Qfhn I IC-0, N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
Iocati .
_� I have no objection to this proposal.
f 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, 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.
f 1 do not wish to waive the 1 setback requirement.
(Property Owner Information)
t l.0 t A0 (A �,ory
Signature / ' �l1
Print(or Type Name cJ
e Number
—I.—I f
Date
(Adjacent Property Owner Information)
� >.S — SSUS 1�
Telephone Number
Date
(Revised 611812012)