Smith, Jason

nCAMA / ❑ DREDGE & FILL No. 75920
.. A B C D
GENERAL PERMIT Previous permit#
I New ❑Modification ❑Complete 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 15A NCAC / % / 1/ �!
YJRules attached.
Applicant Name Project Location: County
Address r i 'f ' / "g\City - � Y State (- I ZIP
Phone # (' I'ti) ' E-Mail
Authorized Agent.t i lr i r;
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ FITS
AEC(s): LJOEA ❑HHF ❑IH ❑UBA ❑N/A
❑ MS.
ORW: yes / no PNA yes / no
Agent or Applicant Printed Name
Signature ar Please read compliance statementon backofpermit"
Application Fee(s) Check# v
Street Address/ State Road/ Lot #(s)
City ZIP
Phone # O River Basin <".
Adj. Wtr. Body i !`; F" (nat. /iflan /unkn)
Closest Maj. Wtr. Body }
PermitOffcers Printed Na.
Signature
Issuing Date Expiration Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
'son I hereby certify that I own property adjacent to Jn� 5m I -�7 's
Name of Property Owner)
property located at n WCW
-�-y� (Address, Lot Block, oad etc.)
on +L�� in CC 7h_ N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locati
1r+p� I have no objection to this proposal.
1 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.)
I do wish to waive the 15' setback requirement.
I" I do not wish to waive the 15' setback requirement.
(Pr Owner Information) (Adjacent Property
/Owner Information)
StJ4 s 0 n Sm +h Sh nature*
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Print or T Pe ame. Print or T e N me
1 o 59Y lrl ia� t_ l 1 U s �T l e rt� 17r .
vL
Telephone N tuber/email address
,67,�
Date
(Revised Aug. 2014)
*Valid for one calendar year after signature*

RECEIVED 12/03/2019 12:41 9103271372
Hellertown Area Library 6108388466 p.1
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �L (t �) t i f ))?) Is
C (Name of Property Owner)
Property located at ) `) C: i" I i 1, ri I1 ' � 'r + l
on :FC
(Address, Lot, Block, Road, etc.)
�10 �� rCl �' '-� / N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
t
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 must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
11
I do not wish to waive the 15' setback requirement.
'Valid for one calendar year after signature"
(Ad scent roperty O ner [nformation)
signalur *
3
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Pnnf or Type Name
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On
Mailing Address
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Crty"Statelzip
Telephone Number/email address
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1 / (Revised Aug. 2014)

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
I,
Name of Property Owner Requesting Permit: jo SD n Jm A
Mailing Address:
Phone Number: % / d' / ////
Email Address:
I certify that I have authorized
Agent 1 Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located 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 QWer Information:
Print or Type Name
©wrfJL
Title
/Z 13 1
Date
This certification Is valid through

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