74609D - Bailners

CAMA / - DR, IIIPGE & FILL No. 74609 A B c
GENERAL PERMIT Previous permit #
.cSNew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous ermit issued
As authorized by the State of North Carolina, Dep ent of nvironmental Quality /
and the Coastal Resourc Commission in an are ,27ir c n rn pursuant to 15A NCAC
�`` /// Rules a hed.
Applicant Name �'� C b Project Location: County -
Address Street Address/,State,/Road/ L t #(s)
City
�- i� i� DN State ti�� ZIP- G 91 0
Phone # (?/0 442 1�9 4- Mail
Authorized Agent /V
Affected ❑ CW !NW A ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
algnature , rlease reau corn P 11d11C.e Aalef l lel 11 Vl1 Udt.K V I Pel 11 Ol
Application Fee(s) Check #
City
ZIP
Phone # (�--
Adj. Wtr. Body
Closest Mai. Wtr. Body
/j0& C1�-
Printed Name
Issuing Date Expiration Date

CK,RIPARIAN Pj ffRTY OWNER STATEMENT
�jj
I hereby certify that 1 own property adjacent to Y3 "AA Co tVd(t-�&t f 's
Property located at I y0 `� C A /Lot�ro/A 6i-VO� of Prop ► Owner)
(Address, Lot, Block, Rood, sta.j
on if�,��JKS t f�NNl t. , in TOA Ar' = N.C.
(Waterbody) (CityRown and/or County)
The qVficant has described to me, as shown below, the development proposed at the above
!M!'ne I have no objection to this proposal.
I have ob*tons to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(kktvJtlttal proposing development must 0 in doscdl>pdon bebw or attach a sits dnnWnp)
,AJ4T' 7a S6ALk V,
19
mot /44 to IZ/tK-
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' setback requirement.
7;r7
Informations
S'r'Al
Pant or Type Name
Mai Address
City/;a�atelZip
�-
Teleohonedumber/emai address
Date '
'rTM j40d#,Ljy1
r
' Owner infon
�N
C �,70V
City/5 wzfp
5�97I --t)e
Telephone Aiumberl address
& — t% / 7
Diate *
(Revised Aug. 2014)
''Valid for one calendar year after signature'

_ il a i. &i1L► _ i
/Va
1 hereby certify that I own property adjacent to i61eAM « M 's
(Name f Property Owner)
property located at i�ou C�li4 L� h1r5t fr'i_i/ P
(Address, Lot, Block, Road, etc.)
on , in 77P5AT-'-- W o-4 . N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc'
have no objection to this proposal.
fiL_ I have objections to this proposal.
D88CRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
llftwmew must fat in lose w or fi s site drawing)
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' setback requirement.
(Pr rtY nor Information) (Adjacent Property Owner Information)
S T�re vltlx 4 u 0 IT
�tt5r -
Print or Type Name Print or Type Name
q6q Zi61-f /LCC/i
Mailing Address Marro �Pass
COWS'
Ct 101
0at ee 12 4 ? Z C /►1 cc� i ,r '�� v �' %
Telephone m ' email address Telephone jVud ber / em d ad�ss
Date Date* 5 „ y` C zo I l
JT;iA 4 UW 0 LJi y 9 GwAr L , (im (Revised Aug. 2014)
`Valid for one calendar year after signature*

Dafe Received
Dafe Visited Check From (Name)
Name o1 Permif I.._
Vendor
Check Number
Check
unt
Permit NumbenComments
Revel f or Refund/Reallocated
Columnl
Column2 Column3
ColumM
Columns
Column6
Column,
Column8
Column9
'Jim a,d C th— Hu d
az P rtriers -t ank
35d 00 00 GP Y74609
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