Bost, James Jr.

®❑(3AM411 ❑DREDGE & FILL No. 75784 A B c D
GENERAL PERMIT Previous permit#
dNew ❑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 + ` 1"' .
/ /� ';
.,...,`_.- [3$ules attached.
Applicant Name Project Location: County
Address Street Address/ State Road/ Lot #(s) -'
Phone # ( )
Authorized Agent
OCW
Affected
AEC(s):
❑ OEA
❑ PWS:
011
yes / no
State i ZIP
E-Mail
❑EW JPTA [DES ❑PTS
❑HHF LLIH ❑UBA El N/A
PNA yes / no
i
i
Agent or Applicant Printed Name
Signature ** Please read compliance s tement on backof permit**
Subdivision
City \ ZIP
Phone # O_ _ River Basin
Adj. Wtr. Body
Closest Maj. Wtr. Body
Permit Officer's Printed Name
Signature ,
Application Fee(s) Check# Issuing Date
nat /mane' unkn)
i
Expiration Date

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
(Name of Property Owner)
I
property located at
(Address, Lot, Block, Road, etc.)
on ,in N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
G✓7, 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, 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.
41a1 I do not wish to waive the 15' setback requirement.
(Property wrier Information)
Si utu�rty
Pri>. 0 r ypX N 10 a
fi �Ko L4
Mqiling A�Oess
rrfl�r� N.C. a-7330
city/ate/zip
icr- 7 77- ,y4/q
Tel phope Number/ email address
Date
(Adjacent Property Ow*r Information)
Signature*
Print or Type Name
/y ���ahor�c lif l3E�ufvrlF-
Mailin;Addre�ss . n / /-
%--)" 6'y/ I / V [r
City/state2ip
Telephone Number/email address
io- 11�-/9
Date *
'Valid for one calendar year after signature`
(Revised Aug. 2014)