Waters, Malcolm

®^ ❑'CAMA / L DREDGE & FILL No. 73386 A B C D
GENERAL PERMIT Previous permit#
❑New []Modification ❑Complete Reissue ❑Parflal Reissft'e Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality ) ' f / /I /
and the Coastal Resourceslommission in an area of environmental concern pursuant to 15A NCAC (-i '1 l i ��Rules attaProject Location: Count , Applicant Namg,� YI(% tti, l`l � --i, �-I(4 j � 1 Y
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❑ PWS:
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Agent or Applicant Printed Name
Signature "Please read compliance statement on back of permit"
PermitOfficer's Prig(ed am -
Signature
Application Feels) Check# Issuing Date
Expiration Date

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front If space permits.
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IIIIIIIII IIII I�IIII II IIIIIII IIII IIII IIIIII III
9590 9402 3777 8032 3181 59
2. ArtiCle Number prancer aam a�•.•..o •..�..•�
7018 0360 0001 5709 9473
PS Form 3811, July 2015 PSN 7530-02-000-9053
X
deliveryliddress different ffpm item
If YES, erit@id44YPRS@�i below
DEC 18 2018
Date
3. l
PriorityMail &pr
❑ Adult signature
❑ Adult Signature Restricted Delivery
❑Registered Mall*"'
❑ Registered Mail Reert
El Certified Mail®
❑ Certified Mall Restricted Delivery
Delvery
❑ Return Receipt for
❑ Collect on Delivery
Merchandise
D Signature Confirmatioi
❑ Collect on Delivery Reettoted Delivery
n sm�atum Gnnlirmatio
Domestic Return Receipt I

ADJACENT RIPARIAN PRO,P,�E�RtTY/JOAWNER S'/TATE�MENT, I
I hereby certify that I own property adjacent to °//,o44� � ky�& ANC 's
( me of Property Owner)
property located at '3O 3 CG 1�tOw�' �
(Address, Lot, Block, Road,
on 5o (wo� C✓-r-e cV_ , in 6 � o �cv Te�a� , N.C.
(Waterbody) I (City/Town and/or County)
ThT�cant has described to me, as shown below, the development proposed at the above
locati
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)
P(o&. 'r'� d4i,
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.
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Pry%.Ty��)U'r- �/�CJ L /
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City/State s-g L/
Telephgr�e {Vumber�f ,J—
Date
on)
Telephone Number
�i/vv 30 2 01 $
Date
RECEIVED
(Revised 611812012)
DEC 1 B 2018
DCM-MHD CITY