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Home My WebLink AboutHolsomback, Michael❑CAMA / ❑ DREDGE & FILL GENERAL PERMIT IMNew ❑Modification []Complete Reissue No. 73452 A B C 'j D Previous permit # Q__.. ❑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 ) / �f-/ .. ) (� � Lt7Ry'les attached. Applicant Name #) 1 " f: kU ( 7C Project Location: County Address - C : %{' .;f' E✓ Street Address/ State Road/ Lot # s City PA CviJ State (_ ZIP Phone # 7 Subdivision % J (.''.) E-Mail Authorized Agent ('l -JA yes City ZIP ❑ CW -6EW 111 PTA [I ES ❑ PTS Phone # ( ) River Basin Affected ❑OEA HHF ❑IH ❑UBA ❑N/A jj� r AEC(s): Adj. Wtr. Body 'U� �� SP (at ma /unkn) El PWS: Closest Maj. Wtr. Body ORW: yes / no PNA /Sep / no 1 - �■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■IMMENSE■ .:_.. :CAS■S■■S■■■■■■■■■S■■�■■■■:■N■■O■NNOSE■■ ■ MB\!■■ME■■■■■■■■�CISOSS: NEES■�■■INN■■ ■MM■■■■M■■N■■■■■■■NQ■■■■/�=■■MEM■■■■MNON :EN::: N:'.'■'■EEE:! m '■'■MEWIME■ MEME: ■ENE■ ■ ■■■M■■MM■M■■■■II■■■C■■■■MI■■■■■■■M ■■■■■■■NE■■E■■�■■■RI[il■®■1■■ MEMO S■ M�ilNEM �:: :NMEMEMEME MEN�lu■ ::::::NE !1■■■■E■■■■n■ MEMO ■■G1I so MEMO ■IR1iSE ■■21111111111 �®IIIAMAMON.::::■::•■■■�•:::•■••� INN■ S■■■ ■I�41` RIP,iM!l■■■■■■■■W■■■■u■■M■■■■■■ • ■■■■ ■■[ WOO ■■■■S■ ■■E■::■E■ENE:■■■.E■■�.■�111 ■' ►■■■I■■■■■■■■■ ■ M■ 0..■..... ■■ INS F1M■1■.....■� 1100 ...:::■■lSi7S IN ■■. E::::■■■o :��■I::=:�::■■::. J :=:::::::::�::::::::::::00-1 MEMO IA■■■S■■■..�■■ ■■■■■■■ ■■ES■Ir I�ClS■■ :! =00 �:::::: :::::::::::::ems MIMEME� AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS Name of Property Owner Applying for Permit: Mailing address: Telephone Number: 6 = , ?6 z13 I certify that I have authorized (agent/contractor), to act on my behalf, for the purpose of applying �and obtaining all CAMA permits necessary for the proposed development of l'7 —Sa.> -Z- /--Z�Z- 4/-Z � at my property located at l Lx�IZ-' �,,Vp7 a1 . L : 73 :X.'°'fir` iJ i1t ` This certification is valid through -` _ ^ (date). (Property Owner Information) '��# K--1-64 Signature Print or Type Name Title, co. owner or trustee for property // te Date Telephone Number Emgil Address I hereby certify that I own property adjacent to (Narpe of Property Owner) property located at V / OGJP /L �20'4-0 cpeP (Address, Lot, Block, Roayi� etc.) 7 on /' >� , in _ �/ �'lo /'Yi J% , N.C. (Waterbody) (Ciiy/Town and/or County) The applicant has described to me, as shown below, the development proposed at the above locatly 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) rRf� HC)L>—AI\ID V4'—L J"R 14 f=sgs a '�A/r t-1 Roo ;::- I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift or groin back a minimum distance of 15' from my area of riparian access unless waived by wish to waive the setback, you must initial the appropriate blank below.) I do wish to waive the 15' setback requirement. I " A I do not wish to waive the 15' setback requirement. (Prope Owner Information) Signahrr / % f Print or T� ppe N/a/p7e / Z�/2 Y'COYG f/i1P Jijor�s %fC7 Mailin�,P�+ress 1V/Prr)V /`JC City/State ip �3h`/3 Telephone Number Date T i 'r- r must be set me. (If you PPrintt or Type Name r . 15a 4(C�� Mai inq Ass �s-tddr 71 C St ip, e/epho)(a NuiTber Dale (Revised 611a12012) ADJACENT RIPARIAN PROPERTY OWNER STATEMENT hereby certify that 1 own properly adjacent to �/ C h G 2 l r/ / �lN, �me of Property Owner) property located at � � 7 � � r��`�€' cC%i� /fY ,t,TJ ,�(j� �y SAddress, Lot, Block Road, etc.) on oGJPi' 8?'C�ccp tPe in_ �P✓z N.C. (Waterbody) (City/Town and or Cl ounty) The applicant has described to me, as shown below, the development proposed at the above location. 1% I have no objection to this proposal. I have objections to this proposal. DESCRIPTION AND/OR DRAWING OF PROPOS (Individual proposing development must fill in description DEVELOPMENT gyv3f attach a site drawing) WAIVER SECTION I understand that a pier, dock, mooring pilings, breakwater, lboathouse, 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. 0 A I do not wish to waive the 15' setback requirement. (Prope Own Information) -ram Signattr Print or Type Name / ll / /7_ �fZ �GJYGC(/SF c�/1+rrr �y Mai' i �drs/ / 7 City/S6te2ip 33 � -s"s"y - 3 d y3 Telephone Number Date (Adjac nt Property Owner Information) SS9i atme "r} V CZ, r-raLA A Print or Type Name nnaa��ding Address City/State/Zip Telephone Number .�2 -ra -/y Date (Revised 611812012)