71789D - Blizzard

CAMA / DREDGE & FILL N2 71 789 A B C (1�
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 7� 1 (� �j
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC V I � 1 � � `�4
,/� yj � Rules attached.
Applicant Name �J t_ (aN �%1. I Z Z Project Location: County
Address N Street Address/ State Road/ Lott #(s)
City�E N N NUJy 1 L L C State NL ZIP � 2� �'" C U (I yl
Phone # E-Mail Of %� I � z 7a' ✓ wtS Subdivision
Authorized Agent N It % P� 6 ' rr ' `�' City �2 v / t (7t1lI ZIP
Affected ❑ CW rfW ❑ PTA rS ❑ PTS Phone # ( River Basin �v C&IL
AEC(s): ❑ OF.A ❑ HHF ❑ IH ❑ USA ❑ N/A Adj. Wtr. Body o Sark' SlAd'
1-1 PWS. n at an unkn
ORW: yes /� PNA yes no
Closest Maj. Wtr. Body
Type of Project/ Activity 01 A" h ( i V
Pier
Fixes
Flom
Fingi
Groi
Basir
Boat
Boat
Beac
Cah(
Shor
SAV
Mor
Phot
Wain
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A building permit may be required by: V A T
( Note Local Planning jurisdiction)
Notes/ Special Conditions ---�—
rle,', 17�("27eq�
or Applicant Printed N e
Signature '""`' ,l` read mpliance statement on back of ggrrpi;""�
f2v
Application Fee(s) Check #
❑ See note on back regarding River Basin rules.
PE icer'ss Printed Name
-/ -19
Issuing Date
7
Expiration Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to-- 1641 Z ,A�1' � Is
(Name of roe Owner)
property located at _ Y- 5-c 4 c ,. �� � <-,, v 7 (� i�U �Vr
on
(Waterbody)
dress, Lot, Block, Road, etc.)
_ in C / Y , N.C.
(City/Town and/or County)
The applicant has 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 rill in description below or attach a site drawing)
7`IL rt/ 1CxS c
- WAIVER SECTION -- --
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin mu t 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) (Adjacent Property Owner Information)
Signature
-A % L! Z7-" D
Print or Type Name
_ZzLg /J N-�- //- rot
Mailin Address J
crtyisrle��
Telephone Number
9 - z. -- 4
Date
-7)
SiWlure n
Prin or T e Naae
ll cc,�t
g Address
It
Cily/,S(aMipq -7 -74 O 13
Telephone Number
Date
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Q >� gL/Zz/42,2 P '1-x— s
(Name of Property Owner)
property located at t C.T
(Add ess, Lot, Block,.R.oadz a c.)
on , in v/-— C t N.C.
(Waterbody) (City/Tow and/or County)
The appli ant has 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)
�b
I understand t at aWpier, doc
minimum di ce of 15' fr
ac , you must init'
mooring pilings, bre
my area of riparian
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
0 .� c
Signature
D ./,' /�jL/ LzA-2W
Print or Type Name
114 C/ N /VC- tt-go3
Mailin Address
�6 -,is l �� �J. C
City/State/Zip
Z8"3 ((- q
Telephone Number
Date
)ute, , or groin must be
wai d by me. (If you wis
(Adjacent Pro erty Owner Information)
�Al
*ature, j� b( Q b
Print Tyoe Name
Mai g drn*
�( '
Citn1,t,I cjl 2-(
Telephone Number
Ib- 7cl�• I10)
Date
(Revised 611812012)
)acK a
waive

Date Received
Dafe De sited Check From Name
Name of Permit Holder
Vendor Check Number
Check
amount
Pe if Number/Comments
Receipt or ReruWlReallocated
Columns
Column3 Column3
C.1-4
Column5 Column.
Column?
Column.
Column9
/t/1019
e R acd Mn fte lez r
F k 2649
S 20000
GP #71789D
JO rd 6971