Blindenhofer, Phillip

�L7CAMA / ❑ DREDGE & FILL %04
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GENERAL PERMIT Previous permit#
ftlNew ❑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 15A NCAC
' © Rules attaled.
Applicant Name t , i! (~. (- ` Project Location: County
Address „' 1 ' Street Address/ State Road/ Lot #(s)
City . State i 1 ZIP " " 1(
Phone # ('-) fE-Mail Subdivision
Authorized Agent of .�' i (' I� )1: I City ZIP
Affected OCW ZIP --
El 0PTA ,K]ES ❑PTS Phone ( ) - River Basin
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body (nat /man /unkn)
❑ PWS:
ORW: yes / no PNA yes / no Closest Maj. Wtr. Body
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Agent or Applicantt Printed Name Permit Officer's Printed Name
Signature 't't Please read compliance statement on back of permit'*'* Signature
OVS�Nr9 �
Application Fee(s) Check# Issuing Date Expiration Date

02-09-'15 13:55 FROM
T-017 P0001/0003 F-056
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CCDEW
North Carolina Department of. Environment and
Division of Coastal Management
Pat McCrory Braxton C. Davis
Governor Director
Date I a s 19
Applicant Name Tw I &L//ti?'3t✓Jl l } 61--�1"
Mailing Address 3-36 W/ND/14r� Waa'-J)S tad q
Natural Resources
John E. Skvarla, III
Secretary
I certify that I have authorized (agent) ?Pq$x-- _ _ to act on my behalf, for the
purpose of applying for and obtaining all CAMA Permits necessary to install or construct (activity)
at (location)
This certification is valid thra
400 Commerce Ave., Morehead City, NC 28557
Phone: [phone] FAX: 252-247M30 Internet; www.nccoastalrnanagement.net
An Equal Opportunity %Ammiative Action Employer
N rthCarolma
No . - llY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 1 LL) P 13 2 I id tFe�J }}ate?? 's
(Name of Property Owner)
3
property located at 36 >� 1 Nb)A6 Wbbl>S �'A
(Address, Lot, Block, Road, etc.)
on,,�QDi �1��� in$T� N.C.
(Waterbody) (Gown and/or Coun
The a plican as described to me, as shown below, the development proposed at the above
to i
C.
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)
V4'AIVtK StG I IVN
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.
do not wish to waive the '15' setback requirement.
(Property Owner Information)
S�'gnnature
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Print or Type Name
33a tJI► ,,, wocsbs
��Mailin Address
C'
City(State/Zit�,�
Telephone Number
Date
(Adjace t Propeqy Owner Information)
ig�atu� .
Pr' tgr pe Name
15 U)N'P/'46
(:�viClofc rJfn .._
S�J� �,t d�d� �hon Number
WE
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to I LLl P 2 ) .ld t715)J 4+z;ry s
(Name of Property Owner)
property located at 336 to I ND)>46 /,J0ZsbS U-)Ve f
(Address, Lot, Block, Road, etc.)
on , in T7V'P f�T FCP?--TVfaG —, N.C.
(Waterbody) (Gown and/or Coun
The applican as 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)
WAIVtK 5tG 11UN
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 Owner Information)
la-`-t-19
Date
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