Jolly, John R. Jr.

-� ®CAMA / ❑ DREDGE & FILL No. 73995
GENERAL PERMIT Previous permit# A B C D
—]New ❑Modification QComplele Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Cclistal Resource
's Commission in an area of environmental concern pursuant to 15A NCAC If
❑ Ryles attached.
Applicant Name - /j Project Location: County
Address < �� 1, i 't !� (,� �' j -'� ( J� S�reet Address/ Staile Road/ Lot #(s)
City I C G l st l.� " State IA ZIP / {
Phone #'{a6 ( jI —0t E-Mail Subdivision -
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Authorized Agent ty /
i -,. �� t l ! �. t• ZIP Ci t 1>
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Affected CW I7 TA ❑ ES ❑ PTS Phone #� ( —� /' R ver Basin
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AEC(s): Adj.Wtr.Body ✓ f i ,�.7(hat man /ur
ORW: ye ElP o PNA yes / ' Closest Maj. Wtr. Body— -; ��1(c� j ., {—� }< .�„� • .�-`=(
Type of Project/ Activity
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MEMEEEMMEeNML
Agent ur
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Signature "Please read compliance statement on
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k of permit"
Application Fee(s) Check #
Permit Officer's Printed Name
Signature ..�
Issuing Date � / Expiration ate

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: —� c/S N R, r 41 y, =;,O
Mailing Address: 111-2- GAAA/,De G'./R-"
Phone Number: C/F-3
Email Address: i<,o„?
I certify that I have authorized 66,Qf'/�, 5(y/7w A.4-)rw"'rz /.ji]/&C_-S' do-41,^r !_�lfa
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: Do ('„c' e0Vx7'PV07-&,d�
at my property located at 600 E BLAe.. 1119AV'6 W, 1,20AL NO eiZ;L,
in /UA7-oe2r-.7- 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 Owner Information:
Sign re
mNN A, --c.t.c�/ .T
Print or Type N me
Title
o � / I! t
Date
This certification is valid through C X /06/
RECEIVED
APR 0 4 2019
DCM-MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER
-`STATEMENT
I hereby certify that I own property adjacent to
ame of Pr erity Owner
property located at 4i ti W' �I�� } � t ; �m �iFt,-ei
�} 1 (Address Lot, Block, Ro d et )
on �Vti1" 17f7 �r`2F� in 1 lie' , N.C.
(Waterbody) (City/Town andldr out
The applicant has described to me, as shown below, the development proposed at the above
location.
l� 1 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)
DIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distance of 16 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.
irropeqy owner Information) (Adjacent Property Owner Information)
l 46,
- Qi4
'Valid for one calendar year after signature'
ephone Numberl email address
�;7 f RECEIVED
� �e (RRevisedAug.201,APR 04 2919
DCM-MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to l o ///?l '-r /- Zy r2 's
(Name of Property Owner)
property located at 6o 6 t6c,c/fZ fb/AlrC AoA4 /Jloaa.dct9,e e,/ 7-y7 ,AQe a-P3'.s7
(Address, Lot, Block, Road, etc.)
on 1V6mIPo1;,.-' Pwim N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatiop.
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)
/J7rAeiaszr�
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.
(Property Owner Information) (Adjacent Property Owner Information)
ity/state/Zip
�%%dJ-,G'/ 9, G/ F_
Telephone Number/email address
02. / / t�
Date /
"Valid for one calendar year after signature'
�?/ 2l
Date*
RECE\VEO
(Revised Aug. 2014) 10
PR 0 4
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