Tyson, Jeannie

�CAMA / ❑Y(DREDGE & FILL O
.� N . 78405 A B ,, c� D
GENERAL PERMIT Previous permit#
,�NeW ❑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 r? �� • j <�� --- .� _ l' ! 7� •:*1/_`-("f i
❑ Rules attached
Applicant Name �P 1 1 i r I E �-1 n/ )
Address
City nn•' ' Stateh(' ZIP I_&C
Phone # E Mail `
Authorized Agent i �� )( `i7117Px �• � yf�!
Affected ❑ CW ✓&,EW . & PTA �>� ES ❑ PTS
AEC(s): El OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ff
ORW: yes,/ no ) PNA yes /�no�,)
Project Location: County (' \ i v � f `l
Street Address/ State Road/ Lot #(s)_ )
Subdivision
City 1 ,l ,, _ ZIP —
Phone # O River Basin
Adj. Wtr. Body '(natl/man /unkn)
Closest Maj. Wtr. Body ^t +-i \ I It � C —
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� -I f or Applicant Printed Name
TV nature '*Vlslease 44ccompliance statement on back of permit"
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Application Fee(s) Check #
PermitOffcer s Printed Name ,A
SignaS,ure /
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 41CA'JV 44-
r
Mailing Address: '-1-507 I<j . f :A e,j
Phone Number: % 5 2- rf i -? o •- S 7 3 0
Email Address: J�ANN + If V� S, C-C
certify that I have authorized ?S . 5�Ar °NA-r-:
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: (���co.4.9��( r 04
h9�(A d[QJ•L L " lh tor", LoAL. X CW A tL"a
at my property located at 4LQ
in OAVQ� _County.
l furthermore certify 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.
Owner Information:
Signature ..
01x3.1iKc- YVI
Print or Type Name
Title
Date
This certification is valid through — I 'Z O

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �11EA y-i, - 0, , -134Svri -
property located at 1 3
Owner)
I
(Address, Lot, Block, Road, etc.) /-,,
on Ae'0.r� /P in C'MV"cc1, , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatio
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)
(A)
`' �i e- -75 to
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g�.w,w� 0 Q
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T7*
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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.) �
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15'
C (Property Owner Information)
I
—j54-7 k) . 4-AL V w 4 ^ U4
Mpiting Address
fr..trrr� CJ oe
Date
S 6
ess g,�.gaC co.w,
z
requirement.
Property Owner Information)
Si nature*
„J;s
Print or Type Name
alp- roSG- oSs i
Date*
C. Z i2o"]
'Valid for one calendar year after signature"
(Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to -) e�N N �C b'y , S.n,
Name f Property Owner)
property located at 6 S p T3 &V •,i s CA" ��
on %\%'� Qse
(Address, Lot, Block, Road, etc.)
aye r , inN.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
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)
v' R-&C. - S-0 JA'
AS DCc �
, e 9 , N V" So'k-
(.� N"'T f3s CoT�ay .,
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the lk setback requirement.
(Property Owner
Ui N Aa 0 E- VVI, a d 1 kT^ Q
or Tyne Name Print or
.Z-
y
ent�Prroo
l'ype Na
Address
25)- 0-1z o e o; -6e1
Telephone Number/ mail address Telep r 10A22.(,4 iDla"�
Dale �, Dare*
Owner I
C ZsS6©
/email
y X eJv-(14w. 1S
Ga- vK
(Revised Aug. 2014)
*Valid for one calendar year after signature*