Mejia, Andrew

®❑CAMA / ❑ DREDGE & FILL No. 75292 A B C D
GENERAL PERMIT Previous permit#
❑O New ❑Modification []Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality i
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
El Rules attached.
Project Location: County Applicant Name j
"-r
City
-State, � j /'ZIP
Phone # OBE
)' -Mail
Authorized Agent
❑ CW
❑ EW ❑ PTA M ES ❑ PTS
Affected
AEC(s): ❑OEA
❑HHF ❑IH ❑UBA El N/A
❑ PWS:
ORW: yes / no
PNA yes / no
Street Address/ State Road/ Lot
Subdivision
City
Phone # (
VAN
River Basin
Adj. Wtr. Body nat man unkn
Closest Maj. Wt_ R_d, " ; i
MOM
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or Applicant Printed Name
Signature "Please read compliance statement on back of permit"
Application Fee(s) Check #
PermitOfficer's Printed Name
Signatjure
Issuing D, to
Expiration Date

V rem
ack°kre-ss
AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Hk ( ac 2gs 9
Name of Property Owner Regi
Mailing Address:
m 3 0A-S
Phone Number:
Email Address:
► certify that I have authorized
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: A6'
at my property to ted at
in 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:
Sigln tur
IY ILl lr�c� V C--o W cI t,
Print or Type Name J
Title
/z/
Date
This certification is valid through I 1.
cL
Alc—

ADJACENT RIPARIAN PRO-P-E�RTTY,�OWNER STATEMENT
I hereby certify that I own property adjacent to ` �, \ Gcyy7� C
of Property
I
property located at t TJ J C'Vxlk 1 I- 1J —_.
(Address, Lot, Block, R d etc.
on _ y`ref:J IL bl � in 1-1 _ N.C.
(Waterbady) (CitylTown and/or Co ) ry
The app' nt has described to me, as shown below, the development proposed at the above
locafi
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)
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.)
-� __ _- _wish to waive the 1 b' setback requirement.
/J I do not wish to waive the '15' setback requirement.
(Property Owner Inform on)
Q
Sfgnan+rc�
Print or Type Name W (WCrnri��,�
MeilingA/dres 1 J
= u 4//e
ify1Statolzip910-� -d;Z 7
Telephone Nurn�t er,(e sit a ress
— iff X�—/ --- --
Date
*Valid for one calendar year after signature"
(Adjacent Property Owner Information)
.Sign+ah;re* _
Print or Type Name
Mailing Address
City/state2ip
Telephone Number email address
Date
(Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STA'iEMENL
nA J F'
1 hereby certify that I own property adjacent to
property located at
kmuuress, LUc, otvcn, vau, aw.t
on ec,) 1Jfc _,in S,npn,r)� cru n5 ot.) _,N.C.
(Waterbody) (Cityao n and/or County)
The applicant has described to me, as shown below, the development proposed at the above
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 to waive the setback, you must initial the appropriate blank below.)
__ I do wish to waive the 15' setback requirement.
Date
I do not wish to waive the '15' setback requirement,
(Adjacent
Information)
.Swnature' v
Print or T e Naw
rt9aili?NL75 �C Z 6o
city/state
Telephone Number/email address
Pate*
(Revised Aug- 2014)
*Valid for une calendar year after signature'