NCWRC (2)

®�CAMA /-❑ DREDGE & FILL "' NO. 744I4 A B D
GENERAL PERMIT Previous permit#
l7'r4ew ❑Modification [JComplete 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 I SA NCAC ,
r / 0 1i / ❑ Rules attached.
Applicant Name _Y - `\'�c �� ` Project Location: County
Address J E-X4` Street Address/ State Road/ Lot #(s)
City State /"rZIP
Phone # ( W % -036 S E-Mail Subdivision
Authorized Agent 1 j!' c' �r ' ' City �/ /v i l` ' ZIPAffected
❑CW DEW Ea�PYX El ES ❑PTS Phone# ( ) River Basin
AEC(s)a El OEA Li' HHF ❑ IH ElUBA ❑ N/A
❑ PWS
ORW: yes / no PNA yes. / no
Adj. Wtr. Body I mat /man /unku
Closest Maj. Wtr. Body 4 - --- -
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or Applicant Printed Name
Signature "Please read compliance statement on back of permit"
Application Fee(s)
Check#
Permit Officel s Printed Name
_1
Signature
Issuing Date 5x0irationDate

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to._ SSA. {c a { t/oriZl C ra in♦ 's
e of Property Owner) m
property located at �t/G j,/ , (�� ; �� a��-(N �� �
I (Address, Lot, Block, Rod, etc.)
on _ gg7�i'ov -5y✓v (1 in Geda — N.C.
(Waterbody) (City/Town 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.
AND/OR DRAWING OF PROPOSED DEVELOPMENT
See a h�c4J 12*14&4
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) ;(Adjacenr arty Owner Information)
Si toreel ,e / // a�C`Oture* Cro
Print or Type Ngme Prin%Type Name
'17100, /t1k�f�6lo 6✓c17' J av Slf�
Mailing A dress Mmai6ng Address
City/state/Zip ee / / Clty S�tate1
'D70 6-5 /mnMlE� GOOt e: d�«•,( (,r+'•a o?.telzfP .s-O.20/
Tel h ne Npp ber/email address Tetephor� ryumber/email address
3%i.5// 9 tr/e %o
(Revised Aug. 2014)
*Valid for one calendar year after signature*

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