Ignatieff, James

IJ CAMA / ❑ DREDGE & FILL No. 75284
-. A B C D
GENERAL PERMIT Previous permit#
MNew ❑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
[K] Rules attached.
Applicant Name I_ ' Project Location: County
Address Street Address/ State Road/ Lot #(s)
State /J( ZIP
Phone # ( '') / / / E-Mail
Authorized Agent
Affected ❑CW ,.MEW 'El PTA El ES ❑PTS
AEC(s): OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / no PNA yes / no
Agent rApplicant Print d Name
Sf n-tur •*Pleasere dcompliant: tement on back permit
!; — 7g�r g
Application Feels) Check #
Subdivision - I ` i
City ZIP
j.
Phone # O River Basin
Adj. Wtr. Body i(nat_/man /unkn)
Closest Maj. Wtr. Body 1' ! W I
Permit Officer's Printed Name
Signature
/
U1,1��
Iss ing Date Expiration Date

Adjacent Riparian Property Owner's Statement
Adjacent Riparian Property Owner:
Section Number: I _ Lot Number:
Name:
Address:
Telephone lumber:
E-mail Address:
1 hereby certify that I own the property acliacent to:
Section Number: D— Lot Number: _L,�).1 -
Owners
Address:
\mne:.�
Telephone lumber: S `:�J, — 1
E-mail Address:
7Y�L4�
The individual applying for this permit has described to me the scope of work as shown oil the attached copy of tite
"Description and Drawing of Proposed work" form and have no objections to the proposed work. I understand that
docks. pilings, tie poles or any other marine structure must be set back a minimum of fifteen feet (I S'-0") front uty
I iparian line unless waived by nre.
I do not wish to waive the setback requirement.
I do wish to waive the setback requirement.
Adjacent Riparian
Print'Name CT
Date o8A--t;a _
0 a PL--
�� 2u
s IG— �L

Adjacent Riparian Property Owner's Statement
Adjacent Riparian Property Owner: !!\\
Section Number: .� Lot Number:v
Name:
Addres
Telephone Number:
E-mail Address:
I hereby certify that I own the property adjacent to:
Section Number: — Lot Number:-2—a)--t--
Owners Name:
Address:
Telephone Number: z� ` `Z `�
E-mail Address:
1Ce�` 66
L
The individual applying for this permit has described to me the scope of work as shown on the attached copy of the
"Description and Drawing of Proposed work" form and have no objections to the proposed work. I understand that
docks, pilings, tie poles or any other marine structure must be set back a minimum of fifteen feet (15'-0") from my
riparian line unless waived by me.
I do not wish to waive the setback requirement.
t,A do wish to waive the setback requirement.
Adjacent Riparian Property Ow er:
Signature)
Print Name
Date
2
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4v
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