Williams, Steve

ACAMA / Lk DREDGE & FILL
�. GENERAL PERMIT
ONew ❑Modification ❑Complete Reissue El Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quali
and the Coastal Resources Commission in an area of environmental concern pursu
Applicant Name 'r 1
Address_ k' � i '^ S IV f
r"
City State / /i ZIP
Phone # ( ) / 7/) 7 " ' E-Mail
Authorized Agent /i /'k•
Affected ❑ CW b EW Q PTA _N ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
ElPWS:
ORW: yes /, no. PNA yes /. no,`
i entor Applican rented
y
Sjgnature "t Please read compliance statement on back of permit"
!'i 167�
Application Fee(s) Check #
No. 75948 A B (C D
Previous permit #
Date previous permit issued
ty
ant to ISANCAC
L9 Rules attacrd.
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision
le
City / ZIP
Phone# (�) River Basin
Adj. Wtr. Body _ _ gnat /man /unkn)
Closest Maj. Wtr. Body
PermltOffice PJmted Nafne
Signatyre
/
!r l� -
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT. APPLICATION
Name of Property Owner Requesting Permit: S�'eJc W • <<.e.—S
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
g 5o s 1GIV-14 lLL TIz
j7NLe IGa N e- Z'14 t5
c�)Idj - F515. 7D7-7
igw:IhavoS I0504D(Nc rc'.cgm
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: (\'e.J V)
�,¢a.Ja1� ati'hro..� t)f' 2e.�SlitiC Will,
at my property located at II Z r & 66 r- U, le. C ,
in 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
W \LL t 92,M S
Print or Type Name
Title
06 I Z01 °l
Date
RECEIVED
This certification is valid through I l I 06 120 2
NOV 12 2U19
DCM-MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to 6fe JL LJ A(ate.- ') 's
_. (Name of Property Owner)
property located at
L
(Address, Lot, Block, Road, etc.)
on 'o✓jC Sp✓•( ,in �tGS N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loca
I have no objection to this proposal.
____— _..___1h�v�QbjQcfions�.o_this_pr_npasaL__
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
5 D F e-r�SF, wS
O Ic( 4�0
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.
(Prop rty can
er Infgr ation)
Kif^
Signature
S%ttl'6 wh-LIA61S
Print or Type Name
550s i4/e"U.1- 771t_
Mailing Address
R AGEr'r, 6 A, N c Q1:5
City/state/Zip
9i9-9is-7o77
Tele(' 7Number
Date
(Adjacent Property Owner Information)
L-Z ��„�-� ,
S" Ctb
a 'h
I ifing.Ad s
Pi. 'L(UaLL 5;oaPi NC,
City/state/Zip
1S2—q)71--Ir I �
Tole
phpne Number
RECEIVED
Date
(Revised 6/1MJ 2 2019
DCM-MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to b k fe LA)'- ,kr r-1 5 's
(Name of Property Owner)
property located at 12 � � �-�u %c,'�,
(Address, Lot,
onin_
(Waterbody)
Road, etc.)
own and/or County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above
locati n
have no
objection to this proposal. IK 0
bav_e objections to this_pro pos.aL__._.__.___ _ _ ---
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
Ovt�
W
a�A r
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.)
lKt� vim(
_, I do wish to waive the 15' setback requirement. _G,
equirement_GT b"
I do not wish to waive the 15' setback requirement. cote q,'yJA ,, 0AV1t4'1 14--
_ SeAwa 11
party Owner Infor tion)
2 ure
r46' (nl+L LIp,m S
orTvoe Name
Mailing Address
Q.AL i614 / N 27(,o
City/State2ip
51`J-AIS-70-7
Telep one Number
ll �/1 R
Dat
Owner Information)
Print or Type Name
'NiG akleo - 1I/
Mailing Address
Pis NC e9f'<-1 2--
City/StatelZip
4 C n _ /_ C-Jz— 4/9n u
Telephone Number
i,_ iq RECEIVED
Date
(Revised 6/WY0J;� Z019
DCM-MHD CITY