Spencer, Aaron

L'. CAMA / ❑ DREDGE & FILL No. 75796
.., A B C D
GENERAL PERMIT Previous permit#
[-New ❑Modification El 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
'Rules attached.
Applicant Name_ _ _ i Project Location: County1
Address _ k i I/
City r� StatZIP ,7��
Phone # (!! " / f , � E-Mail
Authorized Agent _.
Affected CW aEW i7 PTA ❑ES ❑PTS
AEC(s): LJOEA LHHF ❑IH LIUBA ❑N/A
❑ PWS
ORW: yes / no PNA yes / no
Street Address/ State Road/ Lot #(s) i
City ZIP
1
Phone # O River Basin l-'�'/! i
Adj. Wtr. Body 1 '-TCWnat /fria'n'Yunkn)
Closest Maj. Wtr. Body
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Agent or Applicant Printed Name
Signature `*' Please read compliance statement on backof permit'*
Application Fee(s) Check#
PermitOmcer s Panted Name � J
Signatur
Issuing Date � Ezpiratiori Dale
Agent or Applicant Printed Name
Signature `*' Please read compliance statement on backof permit'*
Application Fee(s) Check#
PermitOmcer s Panted Name � J
Signatur
Issuing Date � Ezpiratiori Dale

JVV W Ie- UMy L,
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AGENT AUTHORIZATION FOR CQMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Aa ro n Spe,ncGe f
Mailing Address: ALI 11aTer(f o-u .Drl 6
Phone Number: Q l b - 3 89- �s91
Email Address:
I certify that I have authorized
/ Contractor
to act on my behalf, for the purpose of applying for and obtaining all CII AMA permits
necessary for the following proposed development: _Ye l n6o- YI�T
at my property located at _(Y%
in U_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 Owner Information:
—�Signature
�'�
_ f7a.ran. ��'JtncJ
Print or ype Name
L/LLB Iw,L4®
Title
/o 116 I zo y
Date
This certification is valid through

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
prc
M
The applicant has described to me, as shown below, the development proposed at the above
logatigrt
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.)
_4W 1 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)
M
Dar
�/k/7-01 q
e
(Revised Aug. 2014)
"Valid for one calendar year after signature'

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at
tMUU1e55, LV[, 01UUKRVOu etc.)
on :raw in' 5 NLia5 ff , N.C.
(Waterbody) (City/Town an/or County)
The applicant has described to me, as shown below, the development proposed at the above
Ioc t� ion.
— d2_ 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.)
_t' ✓� 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 Ipformayfion)
/6/ti -Z019
Datel
Sit, w,,J
r nt or type tveme
71i w0tv �;1 6Y,
(aO j�.2 .1s (�c•,r 176 �ifYGe
,W"11c
Date
address
(Revised Aug. 2014)
*Valid for one calendar year after signature*