McQueen, Ivey

^ PCAN,, p /;.DREDGE & FILL No. 75022 A B (C ;% D
GENERAL PERMIT Previous permit#
IFINeW ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality y ( (
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC //� /
- ❑ Rules attached.
Applicant Name !� r Project Location: County (, , vl
i
Address t. - Street Address/ State Road/ Lot #(s)
City 4.. ` . I_ ' 1 State ZIP
Phone # ( )
E-Mail
Authorized Agent'
-
DC
o€W
-ETII
❑ES ❑PTS
Affected
❑OEA
❑HHF
❑IH
❑UBA ❑N/A
AEC(s):
❑ PWS:
ORW: yes /(no PNA yes /
Type of Project( Activity
Pier
Fixecl
Float
Fing
Groi
Bulk
Basin
Boat
Boat
Beac
Oth
Shor
SAV
i,.k-) r f,--r
Subdivision
City t / ,. n :,: ZIP—
Phone # (_) River Basin /
i
Adj. Wtr. Body ` ' (nat /man /unkn)
Closest Maj. Wtr. Body
(Scale: ,!L. )
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A building permit may be required by: ---
(Note Local Planning jurisdiction)
Notes/ Special Conditions / ! �' "� -
'vit�i , �;,.�.r,.. / 1,
4yesn.,
Please read compliance statement on back of permit
Fee(s)
Check#
❑ See note on back regarding River Basin rules.
PermitOfficar s riled Name
Signature : c; /
-"'"-
C;
Issuing Dat)f ExiSiration ate

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date tT 3' / "I
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent) L II-1 ""'e-"""Jo act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date) /c ' a - / /
Property er Signature Date

)61e
_
0360,U943,
_
9723
a--
6654
\ !(
a'
1%
a'
1%

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Don McQueen Is
(Name of Property Owner)
property located at
Lot,
on
White Oak in awansuuiu N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc
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
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 most initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number/email address
Date
"Valid for one calendar year after signature'
(Adjacent Property Owner Information)
i
(Revised Aug. 2014)

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