Goodson, Cathy

❑CAMA / ❑ DREDGE & FILL
-�
NO. 75291
A B
D
GENERAL PERMIT
Previous permit#
."Cj
ANew ❑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
1
[?]Rules attached.
Applicant Name i
Project Location:
County
Address �) ^- t T
Street Address/ State Road/ Lot #(s)
City 'r%;t 1 16 State ZIP
Phone # ( /) E-Mail
Subdivision
�l
Authorized Agent : r,l
City
i ZIP
Affected ElCw ❑EW ❑PTA AES ❑PTS
AEC(s): 1-1OEA ❑HHF ❑IH ❑UBA ❑N/A
❑ PWS:
ORW: yes / no 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 yr
avg distance offshore
max distance onshore y�
Basin, channel
cubic yards
Boat ramp
Boathouse/ Boadift
Beach Bulldozing
Other
Shoreline Length
/
SAM not sure
yes no
Moratorium: n/a
yes no
Photos:
yes no
Waiver Attached:
yes no
Phone # ( ) River Basin - ;'; • i" /e 7 ,
Adj. Wtr. Body I - _ nat..ma unkn
Closest Maj. Wtr. Body
(Scale:
A building permit may be required by: ty ! it, ❑ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction)
Notes/ Special Conditions j i, ��) �" �. I . IV(N
V'.ti. >,, ��,� !n •i�
Agent or Applicant Printed Name PermitOff cer s Printed Name �(
i
Sig au.r 'r�' Please read compliance statement on back of permit • Signature
��(� 'r
Application Fee(s) Check# Issuitg Date I E piratio Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:"�� "
Mailing Address:
Phone Number: !_ C�I
Email Address:
I certify that I have authorized
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
r\
in f_JA.00) 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 Own nformation:
C�
�v
Signs7
Pnnt_gf Type Name
Title
II d� I / Z
Date
This certification is valid through

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I nereby certify that I own
property located at
to
(N me of Property Owner)
(Address, Lot, Block, Road, etc.)
on /yew R,yer5jp- U . , in _r. N.C.
(Waterbody) (Cityrrown and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
�0 t— I have 2o objection to this proposal.
I have objections to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
b" ( K, 4IAO Aerd3s Tr eN17
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set ba minimum distance of 15' from my area of riparian access unless waived by
me. (if yo ish 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)
(Adjacent Property Owner Information)
Si,pmature*
or Type Name
Mailing Address
City/state2ip
Telephone Number/email address
Daft
(Revised Aqg. 2014)
*Valid for one calendar year after signature`

i nereby certify that I own property adjacent to _
property located 11att
on W- l IC i� (Address,
in
.C.
The applica has described to me, as shown below, the development proposed at the above
locatio
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)
q'ff � aaLl Lk�
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�wis 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 'I setback requirement.
— r
Owner InfornAtIon) / (Adjacent Property Owner Information)
r mature q
�jj�'
Print or Ty. N e ` Print or Type Name
W X g A �re�ss �j Mailing Address
1`T4i_ T �: ` 7 / —
C y Staf p � Cify/SfafeTlip
0,/, �Q, / a,2L� JZ3/
r elephone Number/email address Telephone Number/email address
(Revised Aug. 2014)
"Valid for one calendar year after signature'