Ivey, Tracey

®^� L M :CAA / ElDREDGE & FILL NO. 73964 A B C D
GENERAL PERMIT Previous permit#
g]New ❑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
El Rules attached.
Applicant Name !� h / �. �. / Project Location: County
Address 1 } Street Address/ State Road/ Lot #(s) r
State 1�J1 ZIP r
Phone # ( ) E-Mail 1
Authorized Agent I �( s e l f
Affected O CW 6 Ew _f7 PTA ❑ ES ❑ PTS
AEC(s): El OEA ❑ HHF ❑ IH ❑ UBA ❑ WA
❑ PWS:
ORW: yes / no PNA (Yes'/ no
Phone # O
ZIP /
River Basin ' P
Adj. Wtr. Body U�I «. �- (�3fdman /unkn)
Closest Maj. Wtr. Body —
Type
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Agent or Applicant Printed Name
Signature "Please read compliance statement on back of permit"
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Application Fee(s) Check#
PermitOmcer's Printed Name +
Signat re
Issuing D, to -� Expiration Date
__ 4
Agent or Applicant Printed Name
Signature "Please read compliance statement on back of permit"
,� (;
Application Fee(s) Check#
PermitOmcer's Printed Name +
Signat re
Issuing D, to -� Expiration Date

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NCQENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date .3 —/Z — /�`
Name of Property Owner Applying for Permit:
T %rAcG
Mailing Address:
I certify that I have authorized (agent) /off �/ �'�� to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) z%Z/ �f ,
at (my property located at)
This certification is valid thru (date)
Date
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
An Equal Opportunity \ Affirmative Action Employer— 50% Recycled 110% Post Consumer Paper

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 1'fC LJ 11 1+ %Ra(eq Z— �Q,f's
I (Nbnie of Property weer)
property located at %`1 &&S-V14 sb►-, UQ-
(Address, Lot, Block, Road, tc.)
on C cr in r� � t .m1, n ,� it/ . N.C.
(Waterbody) (Clty/T�own and/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.
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 drawfn6)
oaf Of On q-kl l'ng ba f d cx.< ,
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 wish 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.
(Pro ert �mation) (Adjacent Property Owner Information)
�nnlu M/ e(l MW Signature Qq/ f(pn Q/SM
PnnI or Type I ame Print or Type Name
Mailing A1Id/pss �G a� Mailing Address
G�(dc ors 53o Dn'e,�+,�1 . A/C- . ZP57 /
City/sfate/Zip City/state/Zip
111-99..a-W7/.nq,vel6-)n,yLcorh
3�-Q�7-7;L27
t�
Telephon umbe /emailaddress Telephones umber/e /�ressX4
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Uafe Ihnr'
(Revised Aug. 2014)
'Valid for one calendar year after signature'

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to /�' 1 1. eJ. 7t2uer1,f--. -T-�Y s
n (Name of PropertOwner) /
property located at q6
�^ (Address, Lot, Block, Road, )
on r� r� catew< in eOo%eA in ht Q owl , N.0
(Waterbody) (City/T wn and/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.
-,� 1 have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawinw
oaf lr�f /brfra/tiafibn on ewrs�i J. '80a� dock,
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nnAA S0r7�Q ✓�.e_re. �C)1 e�� BIER vLq{+-
Yls WAIVER SEGTIOIS t� ,
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, oNlo sle, lift, or groin ert'e.
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 appropr ate bl k blow.) A ?r'e;, a
I do wish to waive the 15' setback requirement. r l e Q s@i P f'f� \1 r .0- AY Aw t „
C f I do not wish to waive the 15' setback requirement. l77 + h ill me r-N „ 5.
p —)� G 9cur
(Pro intmation) (Adjacent Property Owner nformation)
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'Valid for one calendar year after signature'
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(Revised Aug. 2014)
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