Smith, Thomas

I 'CAMA / ❑ DREDGE & FILL
No. 74445
GENERAL PERMIT
A B iCl D
Previous permit#
INNew ❑Modification ❑Complete Reissue
❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of. Environmental Quality _ �^•
15A NCAC
and the Coastal Resources Commission in an area of environmental
concern pursuant to
I y
') ' � �
;Rules attached.
'
Applicant Name �;� � 9 1 t� 1 I 1
Project Location: County t i V[
Address l i 4 % VC
Street Address/ State Road/ Lot #(s)L-
City 1.�f/ n State /J;` ZIR'-)
Phone # O E-Mail
Subdivision
, I
Authorized Agent
City ZIP
/Je
o CW .0 EW ] PTA El ES ❑ PTS
Phone # ( ) River Basin
Affected
❑OEA ❑❑❑❑ HHF IH UBA N/A
AEC(s):
' -�
Adj. Wtr. Body %'�! / 1 r ! �ii `f (nat /an /unkn)
❑ PWS
Closest Maj. Wtr. Body
ORW: yes / no PNA yes / no,
MINE
MENEM mommolimmoolm
0 ISMAMA
NONE
mmmmmm=NNEEEEEE
MEMO 0
0
ISO
IS
M
!SESSION
.-IMI
I
=EEINI
IIIIIIIIIIIIIII12=01
mom
SEMEN
MEN
ME!EEEEENNE=mu
mismommo
NEI
HIMMI
M
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■Ill'■l�lY/■■■■■■■■■■■■■■■H■■■■■■■■■■■■■■■■
Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit"
Ir',gIL
Application Fee(s)
Check#
Permit Officer's Printed Name
Signatyte //
Issuing/Date Expiratj nDate

CREATE YOUR OWN
i
DESIGN -A -DOCK
Spec your flotation needs-
rMl
Cati 800-65-8168 or visit www.ea-dock.com

Adjacent Riparian Property Owner's Statement
Adjacent Riparian Property Owner:
Section Number: _ �/ Lot Number:
Name: iL4 'JCG/// �Sloit
Address: /Q (i / /
5vw4
Telephone Number: ��? L/ q p�y�7 / h
E-mail Address: J A l g
I hereby certify that I own the Property adjacent to:
Section Number: Lot Number:
Owners Name: �—
Address:
Telephone Number: `72;3 - -7 9S
E-mail Address: 4Z22/;4/ y�
The individual applying for this permit has described to me the scope of work as shown on the attached copy of the
"Description and Drawing of Proposed Work" form and have no objections to the proposed work. I understand that
docks, pilings, tie poles or any other marine structure must be set back a minimum of fifteen feet (15'-0") from my
riparian line unless waived by me.
I do not wish to waive the setback requirement.
_ I do wish to waive the setback requirement.
Adjacent Riparian Property Owner:
Signature
/ r '
Print Name r[y C'� a L)
Date

IXeL
Adjacent Riparian Property Owner's Notification
by Certified Mail - Return Receipt Requested
Adjacent Riparian Property Owner:
Section Number: ,/Lott Number: U/
Name: �S�h L�Gyn,n L 6U1e5{ L M7 ~/)
Address: '� 3 ( GrilOi z:t t5'j� c5�len 15IA4�� /V
Telephone Number: �D3la
E-mail Address:
I hereby certify that I own the property adjacent to:
Section Number: D / Lot Number: 69/9
Owners Name: —722-o m cs S,sn,
Address: /� DD % C4�SSDGJ�c ry Klee
Telephone Number: % %%
E-mail Address: j iy)/
The individual ap lying for this permit has described to me the scope of work as shown on the attached copy of the
"Description an rawing of Proposed Work" form.
I have no objections to the proposed work.
If you have o iections to the work being proposed, please write the Division of Coastal Management, 400 Commerce
Ave., Morehead City, NC 28557, or call 252-808-2808 within ten (10) days of receipt of this notice. No response is
considered the same as "no objection" if you have been notified by certified mail.
I understand that docks, pilings, tie poles or any other marine structure must be set back a minimum of fifteen feet
(15'-0") from y riparian line unless waived by me.
I do not wish to waive the setback requirement.
I do wish to waive the setback requirement.
Adjacent Riparian
Signature
Print Name