Thompson, Larry

-. FICAMA / Li DREDGE & FILL
No. 75795 A
B C D
GENERAL PERMIT
Previous permit#
PNew ❑Modification ❑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 I SA NCAC
[YRules attached.
Applicant Named I T inli;•, ,`'/j
Project Location:
County ) f -, i
Address i C,I t! , < / I
Street Address/ State Road/ Lot #(s)
i
City �' t State I , ZIP
Phone # ('� ) f E-Mail
Subdivision
Authorized Agent —
City
ZIP_
❑ Cw ❑ Ew p PTA Eh E5 ❑ PTs
Affected
Phone # ( )
River Basin
AEC(s): �OEA HHP OIH El ❑N/A
Adj. Wtr. Body
i-
(nat/friar%/unkn)
❑ PWS:
Closest Maj. Wtr.
Body-.
ORW: yes / no PNA yes no
(dock) length
ME NONE ME ME M
d Platform(s) MENNEN
MOEN
so ME 0 Elm
No
IEEE
MEMO
M
EMEMEMSE
ME
ME
M
Elm
in length
NONE
MEMENEEMEM
MEENE
number
EMS
EMINEEMEME
0
ME
M
ME
NONE
max distance offshore
0 OEM No am M ME M
..MOEN
MEEMMEMEMPENE 11 0
ENE No
MINNININ,
IMINEINEEM ME
No
i
Agent or Applicant Printed Name i PermitOfficer'
Signature .* Please read compliance statement on backof permit* Signat re
,�;r
Printed Name /
Application Fee(s) Check #
Expiration Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 1 grry a&,— 's
(Name of Property Owner)
property located at L-`( 14-L4L L.tJ
(Address, Lot, Block, Road, etc.)
on Co.V\n t in FE AA`% , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
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)
I A
—� dot
A. y/!44
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.
Signature
Z 144d Ay %14tJ JeS,7V—
Print or Type Name
/a LYAtL& LM
Mailing Address
SYI� 0 s 9.rR,4r AIc
City/State/Zip
!�fy-
Telephone Numbgr
Date
(Adjacent Property Owner Information)
41, t..zi
Signat e
hEei-
f-►`e�
f7,49�
(Revised 611812012)

1 hereby certify that I own property adjacent to — al';" Z - , 5; � s
( ame of Prop rty Owner)
property located at ��� � �kz ��_
C (Address, Lot, BI ck, Road, etc.)
on _ in :�.5 N.C.
(Waterbody) (City/Town and/or County)
The ap has described to me, as shown below, the development proposed at the above
to
1 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)
!ol cyir4�
Fr
15o)4 4,
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.
(Property Owt* Information)
Print or Tl/pe Name
O I /— �_y�LL 4 v1J
Mailing Address
Syl 9'� Ds 0
City/State/Zip
!0-(.Lz—St'98
Telephone Nur%ber
/O/ ?Z
Dale
Property
PanPanj or T pe Nam
a � 3q�PJ
li `ddress �<
c�Q131+'_I `oo q� s2
Telephone NwN'& � I n
Dare
(Revised 611812012)