Shelton, Carolyn

11
®^� ❑ CAMA / ❑ DREDGE & FILL (` No. 75972 A B C b
GENERAL PERMIT , „; Previous permit#
I New ❑Modification ❑❑ Complete Reissue PIlaf 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
Rules attache .
Applicant Name"�'%� Project Location: County
Address ;. !. Street Address/ State R ad/ Lot #(s)
City �t 1 �)- i State ZIP 11
Phone # (7 , ` r �t E-Mail l Subdivision
Authorized Agent ------ -- — City l V //L,, ZIP J i
❑EW C(PTA ❑ES ❑PTS Phone# (�7 � V 06. / ( a..
Affected ❑ cw River Basin
❑OEA F-HHF ❑IH ❑UBA ❑N/A /
AEC(s): Adj. Wtr. Bod (III(( G f /i f ( �yl r (nat 6/an %unkn)
El PWS:
ORW: yes / no PNA yes / no Closest Maj. Wtr. Body
Type of Project/ Activity
_ (Scale:
Pier (dock)length_
Fixed Platform(s)
Floating Platform(s)
Finger piers)
Groin length
number
Bulkhead/ Nprap length
avg distance offshore
max distance offshore
Basin, channel i
cubic yards_
Boat ramp
Boathouse/ Boatlift
Beach
Other
Shoreline Length _ ;J_ i ' ! 1 + ' 1 � /
SAV: not sure yes no
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no -- - - - -- - —
A building permit may be required by: ❑ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction) ,
Notes/ Special Conditions
/I),r/ lir //-r_:/j _
Agent or Applica t Printed Name Permit Officer's Printed
t i
Signature r• Please read compliance statement on back of permitiSignature
Applitatlon Fee(s) Check# Issuing Date

JGpa 2J4
FAM
3 3 I .Igrly LOW60
ADJACENT RIPARIAN PROPERTY
/ OWN/ER STATEMENT
I hereby certify that I own property adjacent to /% o� -�
property located at
01
of
/7�19v? llq4
I
I (Address; Lot, Blocky Road, et .) h
on a Own in
N.C.
( aterbody) (CitylTown and/or County)
The applicant has described to me, as shown below, the development proposed at the above
localiop.,
�_ 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)
J'3 I
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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.)
�re4 /557f X -3
G v rl� it
f
�
rc(v 09 i'y� &Y,Jq
I �i�liauE 60f
I do wish to waive the 15' setback requirement.
-- I do not wish to waive the 15' setback requirement.
(Property Owner Information)
*Valid for one calendar year after signature"
ja@cent Property er Information)
1
Date*
RECEIVED
(Revised Aug. 209�JC Q 9 2019
DCM-MHD CITY

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