VanHook, Kenneth

4-
❑CAMA/ ❑DREDGE & FILL No 71677
—. A B FC, ' D
GENERAL PERMIT Previous permit#
❑New ❑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 I SA NCAC t -�
ff tt + Rules attached.
Applicant Name i`' III -Y I j I (% f \ t i Project Location: County {�,Z ) I (-0
}}.
Address { G(r I �' t � Fi -`; Street Address/ State Road/ Lot #(s)
City_ �J�
Phone #
Authorized Agent
CW
Affected
❑PEA
AEC(s):
❑ PWS
ORW: yes / no
E-Mail
,1 EW .,.LI PTA ❑ ES ❑ PTS
❑HHF ❑IH ❑UBA ❑WA
PNA yes / no
Subdivision
City
ZIP
Phone#( )
i River Basin k)P/iA1",f'
Adj. Wtr. Bodyl
Vf. T (Cl/({at /ma/unkn)
Closest Maj. Wtr. Body
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Agent or Appliont Printed Name
Signal re*.•y Please read compliance statement on back of permit•*
Application Feels) Check # '
PermitOPocer's
,A olvweP
ExDiratien Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to N d0 K 's
�/ y , t ne r rropercy uwnerl
orooertv located at t� VV(j� j 9 �2 t; b i
BI ck, Road, etc.)
(Address, Lot,
on I/��fTrTi�_ ���`� ??5NTq/_ 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 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.)
xI do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Informati )
Si nahn•e
2
6l �t or Type N me
Mai Address NC
City/State/Zip.
2 a� 9 Af e�
Telephone Number
�r/a3 /irk
Date
(Adjaa nt Property Owner Information)
Signature
.7)(a 11'zi
Print or Type Name 1
Mailing Address
02te'=na(
City/State/Zip
,5s�—�4'
Telephone Number
Dale
(Revised 611812012)

-, -V
t-
7R a

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that l own property adjacent to ! j� N Al J� l 'f4 VAN HOO K 's
2�6 I W / (N a of Property Owner)
property located at _ E)1 -rA K r'1g Ft. PL.
, / (Address, Lot, Bock, Road, etc.)
on VVIi(Y7l' K.c l e ( —, in — IJRJ �//TAL 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, 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.
atyistatei[tp.,
Telephone Number
Z21c
Date lI `F�7
(Adjacent Property Owner In(ormation)
Sign lure
Print or Type Name
M ling Address
e. r!-vez8s71
City/State/Zip
Telephone Number
Date
(Revised 611812012)