Williams, Joy

®ElCAMA / ❑ DREDGE & FILL No. 73967 A B C D
GENERAL PERMIT Previous permit#
JF]New ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality I
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC (7,
I' ( ip Rules attached.
Applicant Nam�e o'� U I' I I .f f J,) Project Location: County \ nyF p
Address Street Address/ State Road/ Lot #(s) i
City State _ ZIP
Phone # (�) E-Mail Subdivision
Authorized Agent-
i
❑ Cw ❑ Ew
❑ PTA ES
Affected
AEC(s): 7OEA ❑HHF
❑IH ❑UBA
❑ PWS:
ORW: yes /ino> PNA
yes / no
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ Riprap leng
avg distance offshore
max distance offshore
Basin, channel
Boat ramp.
Boathouse/
Beach
Other
Shoreline Length )
SAM not sure yes no
City ZIP
❑PTS Phone # ( ) River Basin /JE'_' o-'e.
❑ N/A
Adj. Wtr. Body /'J: (I nat�'man/unkn)
c.�
Closest Maj. Wtr. Body —
Moratorium: n/a yes no
Photos: yes; no t
Waiver Attached: yes I no f
A building permit may be required by:
( Note Local Planning Jurisdiction)
Notes/ Special Conditions & /,/.
:Agent or Applicant Printed Name
C
Signature ^ Please read compliance statement on backof permit*z"
Application Fee(s) Check#
(Scale: )
'See note on back regarding River Basin rules.
I
Permit Officers Printed Name /!
////,
Issuinngbate E pirati nDate

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date 2-,:v
Namer of Property
/Owner Applying for Permit:
Mailing res
Address: / Jj
! V d,✓f,h ORY7� �Y
VIJ13e tie.
I certify that I have authorized (agent) Ci/yGk 611,, d �'RW e i to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) I , �2�, � pry�p , Doti u�/ 11
at (my property located at)
1/
This certification is valid thru (date) J 1+ n c z(J�
Property Owiter Signature Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 61 �' - I
(Name of Property Owner)
property located at �d� 7 r �JGtS �cV Oj d� OZE9 eelk
�2 (Address, Lot, Block, Road, etc.)��`� N.C.
Oil /�/Gc/sE pCr✓?,J in
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
I
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)
1014
A-r1.0 4
LAU W:1ZI-9 to* I[OL.
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.)
DS
�5 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 Information)
5
0.uuSigned by: (''&
Signature Sikhnf/ UCFg22FECF
J. Dwayne Smith
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number
Date
Print or Type Name
209 S. Glenburnie Rd
Mailing Address
New Bern, Nc 28S60
Cif /State/Zipp
252-S14-4716
Telephone Number
4/8/2019
Date
(Revised 611812012)
NCDOT Assistant District Engineer

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to v'tz
I
located at �Ll��Z) �7 /(Name of Property Owner)
property / /� C, ✓<'xSi�zr�2 - 72'c'
�l 7 (Address, Lot, Block, Road, etc.
on /� z i!5% �{ / ✓t-a( in �_2 =-� -) & .A N.C.
(Waterbody) (Cityrrown and/or Co nty)
The applicant has described to me, as shown below, the development proposed at the above
location.
N I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must till in description below or attach a site drawing)
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.)
z'/ l a-1 I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number
Date
Print or Type Name
L'CL /W 2,✓.: xS//:t✓ e7L
Mailing Add /YC --//
7
City/Statelzip
Telephone Nurnb�r
Date�'
(Revised 6/16/2012)