Cook, Russell

CAMA / !-1 DREDGE & FILL No. 73494
GENERAL PERMIT Previous permit#
IQNew ❑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 15A NCAC —� '' / J
d Rules attached.
Applicant Name bi 1 ti )( Cr Project Location: County -/"
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Address V �y Street Address/ State Road/ Lot #(s)
City 3 (I1 �.f \�_1 ?�t T )_iState —ZIP
Phone # (" / _ P 7r/ E-Mail Subdivision
Authorized Agent
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Affected
AEC(s):
LJOEA
❑ HHF ❑ IH
❑ PWS:
ORW:
yes / no
PNA yes �/ no
City
ZIP
-NES AW Phone # ( ) River Basin .(.`'-�{'
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❑UBA ❑N/A Adj. Wtr. Body r S rfxU 1�L : (naZ /man /unkn)
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Agent or Applicant Printed Name
Signature * Please read compliance statement on back of pe t*
Application Fee(s) Check #

I hereby certify that I own property adjacent to /k 1/,5 SELL COOX-- 's
(Name of Property Owner))
property located at /341 �'�Nl�5c{LA /J4 L0� p
(Address, Lot, Block, Road, etc.)
on QK61-14,eZ in e2eQ1 /- LI'do N.C.
(Waterbody) (Cityffown and/or County)
The applicant has described to me, as shown below, the development proposed at the above
I
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)
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 trust initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement.
Date��
(Adjacent Property Owner Information)
Z
Date
6-�I
(Revised 611812012)

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I hereby certify that I own property adjacent to /C 's
(Name of Propert Owner)
property located at %3� %°E.tJ/�t15 G/ L f} Q Lc�J 0Z `?
// (Address, Lot, Block, Road, eta.)
on C/e-_sue , in Ord/Z-A�y Go. , 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 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 16 setback requirement.
>rz 4VL.�— I do not wish to waive the 15' setback requirement.
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Tele m hone N e
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Date 51Zd/�
(Adjacent Property Owner Information)
Mailing Address
�2GGa2i>72 N �—
City/State/Zip
LSZZu4A<74
Telephone Number
Date
(Revised 611812012)

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