Lewis, Dan

NCAMA/ INDREDGE & FILL No. 73454
-+ A B CamD
GENERAL PERMIT Previous permit#
[NNeW ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality 1 _
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
1 © Rules attached.
Applicant Name)/X ! a Project Location: County / S9 V f /
Address l o / q �0 r l _ a r Street Address/ State Road/ Lot #(s) i
City t Vf, (C State �P( ZIPn �'
Phone # -Y / E-Mail Subdivision
Authorized Agent City ZIP
Affected LJCW L EW -]PTA _ N E5 ,[ I PTS Phone # (—)—.River Basin /i / (-'.( y " ,�e­
❑ Li ❑OEA HHF IH ❑❑ UBA N/A r- /
AEC(s): Adj. Wtr. Body � /, iJ , P / �\ ! (nat Yman /unkn)
El PWS:
ORW: yes / no PNA yes / no - ' Closest Mal. Wtr. /Body"
Type of Project/ Activity 1 ' f �.i '7 f
Pier (dock) length
Fixed Platform(s)
Floating Platform(s) —y
Finger pier(s).
Groin length
number
Bulkhead Riprap length
avg distance offshore
max distance offshor
Basin, channel
cubic yar
Boat ramp
Boathouse/ Bc
Beach Bulldoz
Other
I
Shoreline Length 11 `7
SAV: not sure yes Cn
Moratorium: n/a yesPhotos: yes
Waiver Attached: yes
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent
i
(Scale: , )
®'See note on back regarding River Basin rules.
A
renniwnmers rnuw'
le"5ead compliance statement on back of permit *'r
Check#

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to D„ i/ t, R r
s
Property located at /O� DO / 1 (Name of Property Owner)
"-
Met
P (Address, Lot, Block, Road etc.)
(Waterbody) in ,)7147C
(Cityrrown and/or County)
N.C.
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 drawing)
WAIVER SECTION
1 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 Inform lion)
Print or Tyne Name
/oF l o/yOL„'I-
M�ad/(^ng Add/rQ_ss/7
Date
Iber/email address
(Adjacent Property Owner Information)
Signature*
��<Co Wou/J�T/zi�,�
Print or Type Name
/1:519 r7a419hrIAr 4��ivri
Address
• OCR < o o ff , AC
email
*Valid for one calendar year after signature`
(Revised Aug. 2014)

Date
Print or
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to .J„ A-J � , C s
] (Name of Property Owner)
property located at �o�f lDe /,v 1, , ,t /A
(Address, Lot, Block, Road etc.)
on f'4.4at in / 4yC-71Q7C N.C.
(Waterbody) (City/Town and/or County)
The applic as 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 rill in description below or attach a site drawing)
f;
r . ;.. ,� , > > ` i� _ �.?{nX".'�C>"fit. � i. , � Y� >� E":•� ; ` "�``'T.'�'1C"�' zx n
9t1a7` r 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 Inform tion)
Signature
tE ,o a , Print or Tye Name
/0� _)o/)o
Ma,ilifng Addr,�eess 7j
L/A Y C /o
City/State2ip
Telephone Numberemail address Telephone Number/email address
Date*
Property Owner Information)
*Valid for one calendar year after signature` (Revised Aug. 2014)