Blaha, Kim

®CAMA / I DREDGE & FILL No. 74948 A B f/C D
GENERAL PERMIT Previous permit# L
_, eKew ❑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 Commissio ip an area of environmental concern pursuant to I SA NCAC
❑ Ryles attached.
Applicant Name ' Project Location: County ( r'-/
r State ' ZIP
Phone # (pr�1 ��) �. 1
1 1 A a
E-Mail
Authorized Agent
t❑CVO
❑PTA
DES ❑PTS
Affected
AEC(s): ❑ OEA
❑ HHF ❑ IH
❑ UBA ❑ WA
❑ PWS:
ORW: yes / not
PNA /yes no
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s) - `/✓)
Groin length
number /
Bulkhead/ Riprap length
avg distance offshc
max distance offsh
Basin, channel
cubic
Boat ramp
Beach
Other
Shoreline Length 1
SAV: not sure yes
Street Address/ State R9ad/ Lot
Subdivision
/ t 1
City f ZIP /I
Phone # ( ) RiverBasin <_: `+
Adj. Wtr. Body Y''e ( na[ Yman /unkn)
Closest Maj. Wtr. Body`-
0 7') ✓2(�l /
/' / _> >/i f (Scale: /1/ )
Moratorium: n/a yes no/
Photos: yes ny� _
Waiver Attached: yes no' // C
A building permit may be required by: l..- .d f ❑ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction)
t .
Notes/ Special Conditions
yLLa I-x—,
Sign •s'Please read c6mpliance statement on back ofpermit**
Fee(s)
Check#
h
fcer's(Printed Name
Signature. / /
Issuing Date Expiratioi Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Kl (11C'ik, RL l�
Mailing Address:
Phone Number: I ()c8
Email Address:
I certify that I have authorized
Agent i uontractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: ►nSAW-1% W x 8-10` ujo,%".
I►') lu' 6411 A go-z Av, 1 � t itx�� �iK+. � �"r � off- 3 Xa(p t,A o4ee �lr r of =12X1Z i'f-
at my property located at )t• n" ►Zpi hgy*IS P.J.IMur'sV*-^tt" C,
in( pr County.
I furthermore certify that I 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:
(>-Z)lic-l�
Title
S /'?)_/ 19
Date
This certification is valid through I_/ 1t q
RECEIVED
MAY 2 3 2019
I)CM-NIND CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certity that I own property adlacanl to 11s +ir;t
ro er bcalud at 1.•.i 1`r 1Name'of Property Owner)
p p ty fPly r. ,% ! _ �t'rf.- i a r.," 1 F
(Address. 4ot. Block, i�Road,
ont, t "1_y.. t : -____ In 1 __t--_SS ...,
(W►tarbody) (CltylTown andlor County)
The applicant has described to me, as snotvn oe'ovi_ the development proposed at Ina above
location
__X— _ I nave no ob;ection to [his 1, ropo:+al
I have obleMions to this Proposal
DESCRIPTION ANDIOR 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. Weakwaler, boathouse ]dt. u• groin
must be set back a minimum distance of 15' from my area of riparian access unless waved by
me (If Volt wish to waive the setback, you must initial the aPpr00nate blank below I
I do wish to waive the 15' setback ,equitenneni
I do not wish to waive the 15 setback req trtement.
(Property Owner Information)
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Pnmf or Tyjo. Noire
MnPf%u ichlre?s'
t 1.
r,.fG Ph fl(] fJpall):.'r 1. 1 i
R,'46,?55
•Va ld rot one ce.6udar year after �,.I_.,c:.l,:
(Adjacent Proper Owner Information)
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RECEIVED
MAY 2 3 2019
DCM-MHD CITY

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RECEIVED
op
MAY 2 3 Z019
DCM-MHD CITY

('.
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I': -,cif 's
I hereby certify that I own property adjacent to Y_,� I t�(Name of Property Owner)
property located at
on
in
and/or
N.C.
The applicant has described to me, as shown below, the development proposed at the above
Iocapon.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELUrmtry i
(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 Information)
Dale
"Valid for one calendar year after signature'
(Adjacent Property Owner Information)
.S' ellalure`
l ;rl..,'
Print or Type Nance
Mailing Address
City/state/Lip
Telephone Number/email address
Dale'+�
(Revised Aug. 2014)
RECEIVED
MAY 2 3 2019
DCM-MHD CITY

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RECEIVED
MAY 23 2019
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