Smith, Ransom & Maxine

^� '-CAMA / '.- DREDGE & FILL No. 75935 A B C D
GENERAL PERMIT Previous permit#
[]New ❑Modification ❑Coryltlete 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
/ ❑Rules attached.
Applicant Name 1 Y }';, 1 �;„`n�roject Location: County
Address } Street Address/ State Road/ Lot #(s)
City --- State y� ZIP o I ) I
Phone E-Mail
# Subd Isivi on
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Authorized Agent - -- -'-
Affected ❑ CW ❑ EW ❑ PTA LIES ❑ PTS
AEC(s): ❑OEA ❑HHF ❑IH ❑UBA El N/A
❑ PWS:
ORW: yes / no PNA yes / no
Type of Project/ Activity
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Phone# '(- cJ //%�live rBasin �. 1
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Closest Maj. Wtr. Body�;!_i
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INEMENEEN
A building permit may be required
( Note Local Planning Jurisdiction)
Notes/ Special Conditions
ent or Applicant Printed Name
Signature ** Please read compliance statement on backof permit **
Application Fee(s)
Check#
❑ See note o
i
ar's Printed Name
Basin rules.
Signal uleig' 1q
Issuing Date Expiration Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to FIM LO " 1 1 - l 's
(NamA of Property Owner)
property located at �tlJ � PP GtJ�4� MoA�i41f�,/�� Glt'�I 25&✓r7
(Address, Lot,'Block, oad, etc.)
on Cr i GJO0—na -,inG.aNCI i't' 60 s , N.C. .
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatiory
I have no objection to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
�pffividual proposing development must fill in description below or attach a site drawing)
_� Z"/r1�ILL • ••/. •�, �.w �...� _ Nf l7 00l• 0iWr4h, 1v_ A(?2ILI ZArIp-/ fj
v�l1�Ct-/k�J Ji�G�'P•�i n
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FV-7V(,7,— 00dt f�1i f�IP(h�P�1 SSl Q/kl �l �
WAIVER SECTION - (r��oFze("tc.,
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.
r
I do not wish to waive the 15' setback requirement.
Information)
Print or Type Name -
11 QIL.
Mailing Address
MrAIA+1Afill z�°.53�
City/ tate/Zip
ta. zta• 6q v
Telephone Number
/o • 2Y• IC)
z
nt Property Owner Information)
Si tore
yoc g \le,.-..
Print or Type Name
i ri core- -PA u2 tulle-54-
Mailina Address
RECEIVED
Date Date'
NOV 0 7 2019
(Revised 611812012)
DCM-MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ?AAOM � 11/1%K4 4� MI •C -k 's
(Narhe of Property Owner ,
property located at
on in G%SM+iET `0 • 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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
proposing development must fill in description below or attach a site drawing
11 ' W/ Zi,- PC' 1>P S vlhJi
d
2 � '
Ip. r �—,-� a -is,o -� - b t��0l mvl:i,L
v l twLA, o vJ�sv�rt-A Ci w
0
"AAe
FEpo pskreAP pt Sail fikrV-R,
WAIVER SECTION �`�oo-t�'
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.
(Pro pert Ow r information)
Si nature
H045qiAL Sail RA�Io.•�
Print or Type Name
Telephone Number
to, z 1 • LA
Date
(Adjacent Property Owner Information)
Signature
itil,l(•a�R
Print or Type Name
( 13 Co re W t ' ugeS
UU[G
(Re Ov U T/9w)
I)CM-MHD CITY