Russell, John

LFICAMA, /, ❑ DREDGE & FILL No. 75285 A B C D
GENERAL PERMIT Previous permit#
k7New ❑Modification ❑Complete Reissue Cl 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 15A NCAC
© Rules atta4hed.
Applicant Name \, i Project Location: County i V 1
Address j l ' c \ f Street Address/ State Road/ Lot #(s)
City_ I State 1(ZIP r 7i
Phone # r
( ) E-Mail
Authorized Agent .1
Affected ❑CW /DEW 111PTA DES ❑PTS
AEC(s): LJ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / no PNA yes / no�
CityZIP
Phone # ( ) River Basin
Adj. Wtr. Body / i - -��I. (hat /iii nn')/unkn)
Closest Maj. Wtr. Body 11, e !
Type of Project/ Activity
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Agent or Applicant Printed Name. - -
Signature ** Please read compliance statement on back of permit**
Application Feels) Check #
PeermitOffcer's Printed Name14
-�-LJ
tion Date

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit: \` -s (-C'L-
Mailing addres
16r) y Se A
1\3C-k--)` bf�-\ 50 C 1�5n O
Telephone Number:
I certify that I have authorized 1?C[ 1 S h - ( (agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development ofyTW VL a To�-iKT;tJG
at my property located at 1 CY\) 4 ((A t�
This certification is valid through
(Property Owner Information)
Signature
l �a-� 2uss cu_
Print or Type Name
C��-j tV &
Title, co. owner or trustee for property
Date
Telephone Number
(date).
Email Address

I hereby certify that I own property adjacent to --�' QQ lA o `Z\-kSSE LL 's
(Name of Property Owner)
property located at l0f�N C E (�� ,�QT �� C'U p0(g—
(Address, Lot, Block, Road, etc.)
on -I:C-Li in _ Y\� t 3 N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc ti n.
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)
Op'
- WAIVER SECTION
i understand that a pier, dock, mooring pilings, 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) (Adjacent Property Owner Information)
Signature Signature
P ' r Type Name Print or Type Name
Mailing Address Mailing Address
t U aA N)uYP071- 1
citylstatelzip city/ tat 2i
Telephone Number Telephone Number

ADJACENT RIPARIAN PROPERTY OWN Q cTATEMENT
I hereby certify that I own property adjacent to _-ZQu o 's
(Name of Property Owner)
property located at
(Address, Lot, Block, Road, etc.)
on C .% in _ N� J2OT— t\3 , N.C.
(Waterbody) (CityfTown 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 rill in description below or attach a site drawing)
,� Lt ! T I
WAIVER SECTION
1 t nderstand that a pier, dock, mooring pilings, 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.)
do wish to waive the 15' setback requirement.
> I do not wish to waive the 15' setback requirement.
(Property Owner Information)
--1. r
io ature
Print or Type Name
Mailin/^g-� Address
City/bYate/Zip
ro,C .-)
Telephone Number
Information)
Print or Type Name
C�-.4i(�wFt
MailingAddress
citylsiatelziMr
Telephone Number