Ellis, Charles

M CAMA / ❑ DREDGE & FILL
N. O 78404
1,
®GENERAL PERMIT
A
Previous permit#
e C D
RINew ❑Modification ❑Complete Reissue El 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
/
©Rules attach d.
Applicant Name_
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Project Location:
County
Address, j / 1 /(L
1, )'t re
Street Address/
State Road/ Lot #(s) r%?
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City '�'_'' VI
�e State �'/� ZIP 71��
Phone # O ! y ' f E-Mail
Subdivision
Authorized Agent
City .i i Ir
/
!' I ) ; /tOj ZIP
Affected ElCW .L]EW OPTA Li in ❑PTS
Phone# (
) _ River Basin
AEC(s): ❑OEA OHHF ❑IH ❑UBA ❑N/A
Adj. Wtr. Body
(nat/man/unkn)
❑ PWS:
ORW: yes / (no PNA yes \now)
Closest Maj. Wtr. Body
Type of Project/ Activity
Pier
Fixe
Float
Fing
Groi
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Basin
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Boat
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A building permit may be required by:
( Note Local Planning Jurisdiction
Notes/ Special Conditions i%
Agent of Applicant Printed Name
Signature ** Please read compliance statementon backof permit"
g899
Application Feels) Check #
❑ See note on back regarding River Basin rules.
it Officer s'Printed Namet,
itur
rf
in Date Expiration/Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 1-1 C� , � e 5
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
C—C
A
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: D 6—e'k—
at my property located at ,
in County.
I furthermorecertify that. l 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:
" Zx
Signature
� "-S r JI s
Print or Type Name
Title
RECFIVFO
Date �—
;.;;
L9t.;:- ,„" CITY
This certification is valid through I I
r. 0-3 �)�

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to (f h AIZ-) es C LL.1 S 's
�] (Name of Property Owner)
property located at ZZ T fl 1q " T) r i L
ong, r,a) (Address, Lot, Block, Road, etc.)
in lL S , N.C.
(Waterbody) (City/Town and/or County)
The applicant 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 deycription below or attach a site drawing)
l0
1
zq
L1*��-a
'1? 1 a J- Pat r31
i3x13 Aoo
5
N
5
b
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
,,viV to waive the setback, you must initial the appropriate blank below.)
t ` /
✓ I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner inf n) (Adjacent Property Owner Information)
6* ( �
Date DEC 3 0 2019
(Revised,6/1M'AAD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to if )n p.Yt_.) E5 6L1_15 's
Name of Property Owner)
property located at �� O!a 1 1 J r j' vt
(Address, Lot, Block, Road, etc.)
on C in 19k5 ,
(W terbody) (C�own and/or County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above
location.
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 till in description below or attach a site drawing)
a r0
----or-------is �1
La.
.7! e d r)f Yrt
X
I
i
N
S
b
WAIVER SECTION
BY-13 Aoo
Ba 47
iD L 4
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 waiv the setback, you must initial the appropriate blank below.)
V.
1 1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner InfgrgnatWn) (Adjacent Property Owner Informati9q) _
v�
Dare T T
Tele hone Number
5—
Dare
N Y.
IVED
DEC 3 0 2019
DCM-MHD CITY
(Revised 6/16/2012)