Brinson, Keith

®❑CAMA / ❑ DREDGE & FILL No. 74464 A B \ c D
GENERAL PERMIT Previous permit#
❑New ❑Modification ❑Complete Reissue OPartialgkeissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality I )
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC 1 i / 1'/�% L
Rules attac ed.
Applicant Name__ Project Location: County' \_(
Address Street Address/ State Road/ Lot #(s)
City IV
Phone )_
Authorized Agent
Affected ❑ CW
AEC(s): LJOEA
❑ PWS
ORW: yes / no
IFAI9
❑EW ❑PTA ❑ES ❑PTS
❑HHF ❑IH ❑UBA ❑N/A
PNA yes / no
Type of Project/ Activity
Subdivision
City ZIP__
Phone # ( ) _ River Basin J I
Adj. Wtr. Body : - _ (nat /man /unkn)
Closest Maj. Wtr. Body - — -
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Moratorium: n/a yes!
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A building permit may be required by: (: \�- - El See note on back regarding River Basin rules.
44,
( Note Local Planning jurisdiction)jf�
Notes/ Special Conditions ��-�-�, �, I t. (i _/� -
ZLI
Agent or Applicant Printed Name PermitOffcerls Printed N e
Signature " Please read compliance statement on back of permit'"
Application Fee(s) - Check#
Signature
Issuing Date j Expiration Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMi -NT
J•
I hereby teddy that I own pu,pcily odprcenI In _K�.1•�-�� -- .�-� �- _ •s
(Name of Properly Owner)
property located at _.JJ aJ_� � � r_)_Ir -J-7
---------- _.--
1 (Address, Lof, Mock. Roa$ etc.)
on lf�."1 <-.ft'�'ft _...---- in._n%CI_t)(1n(/.._ - _•N.0
(Waterbody) ((.ily(Town andlor county)
the opplrcanl has desaibed to ire, as shown below, the development proposed it the above
lecahor5
1 have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in description below or attach a site drawing)
jss
1VAPR 2LeD CITY
DCM-MHI understand that a pier, dock, mooringr, b athouse, lift, or groin must be set
back a minimum distance of 15' from ac ss unless waived by ma. (If ydu
wish iowaive the sethack, you n�r�st in
k below.
I do wish to waive the 15 setback requirement.
I do not wish to waive the 15 setback requirement.
(A }scent Property Owrfo n)
�1b'IInIl7/'C
G:
Vale3-10-19
(Revised 6/1&2012)
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I hereby certify that I own piuperry adlaconl to
o
/ .� ) Pr
properly located nl .{ /_ _ •-'• P�[.r%• r (ryan,a operty Owner)
f?� — •.. (Addronn, Lot,It)ck, Road,ftc.)
en _ 1r @_14'.L.__�_i—`.�.(\,------• in _! V Lie%R�1 . N.C.
(waterbody) IC y/Town andlor County)
the apphcont has doscrihed to nu, as shown below, the development proposed at the above
loaabon
_1 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 elow or attach a site drawing)
RECEIVED
APR 2 2 2019
DCM-MHD CITY
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.)
1 do wish to waive the 15' setback requirement.
(P
Date
I do not wish to waive the 15' setback requirement.
Information)
—3 so
1
(Adjacent Property Owner information)
S� nature
�ab�r�
(Revised 611812012)
Scanned by CamScanner