Register, Ralph

_l CAMA / ❑ DREDGE & FILL No. 73979
-. A B CG D
GENERAL PERMIT Previous permit#
Cj1NeW ❑Modification []Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality -'J // % 1 (
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC / / Lx --'•--
-, ❑Rules attached.
Applicant Name (' I Project Location: County L " ,-
Address Street Address/ State Road/ Lot #(s)
,
City T ' '� State ZIP
1
Phone # ( ' �)/, )C' (� ,� E-Mail Subdivision.
Authorized Agent
Affected CW
AEC(s): oOEA
❑ PWS
ORW: yes / no
-p�W -..PTA
❑HHF ❑IH
PNA yes / no
Type of Project/ Activity
Pier
Fix:
Float
Fing
Groi
Bulkl
Basir
Boat
Boat
Beat
Othr
Sher
SAV
Mor
Phot
Wain
El ES ❑PTS
❑ UBA ❑ N/A
' !
/CUB t,ur
City ! ZIP _
Phone # O River Basin
Adj. Wtr. Body - (nat /man /unkn)
Closest Mai. Wtr. Body f ` "
U' X'c% O ;/ •l fc'.11-,
(ScaleW—/
I-
)
-
■■■■■N■■■■■
E•
:
A building permit may be required by: O� S I `� �- ❑ See ngte on back regarding River Basin rules.
( Note Local Planning jurisdiction) iJ
Notes/ Special Conditions 1�/(i P" �r 7 ✓ f '� t �' "( " `
t
i
or Applicant Printed Name
.";'// L, .
Sign/jbr ** Please read compliance statement on back of permit"
Ir" �
p lication Fee(s) Check#
Issuing Date
e-
el7

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 14 's
. , (Name of Property Owner)
property located at
J
�`�, (Address, Lot,
on �K�eN �r�l� in_
(Waterbody)
etc.)
and/or County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above
location.
',4Z / 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)
jJ,t�/�l�ra %j r(oPca G�� ld/ e % f /�n �s1/G�t aPs��©Xlwl« �yr
/1 Gad .7 �A��Q/ooc.`T7r wli.c A ek Cc �O'.S �'"` /r7%-rr
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uexl
RECEIVED
MAR 2 5 2019
WAIVER SECTION DCM-MHD CITY
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.
(Propeffy,Owner Information) (Adjacent Property Owner Information)
T� -�-
Sre `/ 7 Signature* 5�
$at
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Print or Type Name ^ Print or^ Type Na me
/Sn ��v�td�✓ tJr-Z 40,
Maill9 Address'P Mailing Address
City/State2ip � City/State'p J - r
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Telephone Number/email adder Telephone Number/email address
Ihelin ';7,-t- 53i';' 1/X'i9
Date Date*
(Revised Aug. 2014)
'Valid for one calendar year after signature'

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ,e h f f R, 9q 15"7 e% s
(Name of Property Owner)
property located at
/(Address, Lot, Block, Ro`ad, etc.)
on oeee^v 5 , in �ul�e/7L 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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
�C<a7 2.7
�"��
�>^vPe."f7! w �.`c (� ek
s d.-- . `71�{ of Ck w � / 1 e k-1��IiCl( 0 �i-
zvK 7-0' f 111-74 ,_'• Ors T rA "PJe
Pg5t 4)e MGRr^5k WO4 0-
RECEIVED
MAR 2 5 2019
DCM-MHD CITY
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 ou wish to waive the setback, you must initial the appropriate blank below.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Prop ner Information)
SJjg%nature//✓
/�F+GPFF
Print or Type Name
MIN Address'��
u��,e� N'c zs3s3 j
City/State/Zip
Telephone Number/email address
Date
"Valid for one calendar year after signature`
in)
Telophow Number/email address
Ls ) C-?o -1 zoo 1
Date* 0,5>-d I
(Revised Aug. 2014)

fV(, 2-9,r3�
Ls Z 00 -0sq 2-_
RECEIVED
MAR 2 5 Z019
DCM-MHD CITY