Booker, John

AMl EDGE & FILL (� ' / No. 73950
� A A B �C , D
�FNEA/`iL PERMIT Previous permit#
w-l"'lodification []Complete Reissue ❑Partial Reissue Date previous permit issued
11
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
-\- ) /- ❑Ryles attached.
Applicant Name J --� t '` ' Project Location: County `'- ` '- /
Address'
City �' l ' State ZIP
Phone #
Authorized Agent
Affected ❑CW ❑EW OPYA PE5 ❑PTS
: ❑OEA ❑❑ HHF IH ❑UBA ❑N/A
AEC(te
❑ PWS:
ORW: yes /.no PNA yes /,.n9i
Street Address/ State Road/ Lot #(s)
Subdivision
City%fj
Phone # O ( River Basin { '
Adj. Wtr. Body ( / ) c,✓ a man unkn
f
Closest Mal. Wtr. Body 1 "^ /
Agent or Applicant Printed Name PermitOfficp 's PSinted Name _
Signature **Please read compliance statement on back of permit"
Signature /
-7/ z r'('
Issuing [Date xpirati lon Date
Application Fee(s) Check#

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 7vtFN /Yl. IJoa1CC /� SHiFC_ E� s �6a1Ct
Mailing Address: /�0, Box _t5ti
��inry Hh/EL1i WfC, 27,-7'7
Phone Number: 911 631 t7F8
Email Address:alhiH�eok��G
I certify that I have authorized .oM N I Li` 66-13-T
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: RL= -Co USTQuC i /aN o F
t�X(S"r1K)6, DOCK Du.e -"o /-Ika(ZI(.1*WC a+w4Ct
at my property located at /UZ
in / Air 't County.
1 furthermore certify that 1 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:
_962�1 �'_ __04�
Signature
Print or Type Name
� w�1ElZ
Title
3 1 /4 I zv/9
Date
This certification is valid through bl 3 0 I M

DocuSign Envelope ID: 64ED8173-0688-4B62-B761-555BOCC92403
\L1
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to � 10 N.✓ 'Y .S 4 1 r= A / Sodl cx- 's
(Name of Property Owner)
property located at ioy& S � �1 S M 0� � X
(Address, Lot, Block, Road, etc.)
on Co/t2 S 0,72A in 4 1 z-'nl /r1,C N.C.
(Waterbody) (City/Town and/or County)
t.applicant has described to me, as shown below, the development proposed at the above
locgtjop. I have no objection to this proposal.
L 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)
9 / IZ� l ) /y s T✓a c Le i� cU N .S ' r u,� /i.
IZo x r tt 4 i e Z O t 415(, c/c- 94 Hbe-1 Lim
U v V111'�le- �)''N\ a\�
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 unl ss waived by
me. (If you wish to waive the setback, you must initial the appropriate blank belobgCEIVED
I do wish to waive the 15' setback requirement.
FEB 2 0 2019
1 do not wish to waive the 15' setback requirement.
DCM-MHn ctry
(Property Owner Information) (Adjacent Property Owner Information)
Uo uftned by:
�] Lr-
Signature
iala
�
Print or tT e ,t Name
1
Mailing Address
CJ rm r'rli h/L-'Ll� rvC Z.7S'77
City/state/Zip
Telephone umber/email address
l ysr(iy
Date T
*Valid for one calendar year after signature*
or Type
Mailing Address
city/state/Zip
Telephone Number/email address
L�
Date* / //
(Revised Aug. 2014)

(Naml� Property Owner)
property located at C �('v `c 1
(Address, Lot, Block, Roa etc.)
on \ .-1 f (Z iatiin \N„ , N.C.
(Waterbody) (City/Town a d/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.
-_- ---__lheve-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.) RECEIVED
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Owner Information)
or
Telephone Number
Date
FFB 2 0 2019
UUVI-101-11) CITN
(Adjacent Property Owner Information)
Signature,
Telephon N be
�(
Date
(Revised 611812012)

R y
h
4114
t
a ,
Pa.ti�
# �1

Hurricane Florence and TS Michael
Replacement/Repair Request Form
Date of Request:
Property Owner Name:
Address of Property: i n l Q _!�CA 5 �i , 'Q1- ft I I & 10 C
Tele hone Number:
Type of Work:C��l//�)
NOTE:
• The Emergency CAMA General Permit 2500 is for repairs and replacement of water -
dependent structures damaged because of Hurricane Florence and/or TS Michael. The
— — - replacement,- reconstruction and maintenance excavation activities shall conform to
current standards and rules. All work under the Emergency CAMA GP 2500 must be
made in the same footprint of the previous structure with no additions, expansions, or
enlargements.
If any portion of a structure being replaced is within the 15' setback of the riparian line or
access area, signatures of the adjacent riparian property owner(s) must be obtained
acknowledging the notification and waiver of the setback on the forms provided by
DCM.
• Any maintenance excavation or dredging requires signatures of the adjacent riparian
property owner(s) on the notification forms provided by DCM.
Signature:
RECEIVED
MAR 18 2019
DCM-MHD CITY

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: J N M 3100KCeS/(/2LE 6wle5(
Mailing Address: P % 13C)K 5-S
SmITµ rjkZzt) <V Z7S%
Phone Number: "11 � (03 1) 7l g
Email Address: �Oaa <h r160UZrZ (—'0 4 Mad •lvc>ti
I certify that I have authorized Z�lw Ao S
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: Ptct4u log
Foe- Ff'Twt r-r5 P+ /�cg(0 Stet !/-ha
at my property located at 1066 SStrA S#01 F Oe(✓& 6K-L
Fl
in f k FCounty.
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:
=4isf
Signature
Print or Type Name
Ow NEX�-
Title
I 20 / 7010
Date
This certification is valid through b 1 3 C) 1 701 q