72766D - Carroll

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CAM^ DREDGE & FILL NO. 72766 A B (C
GENERAL PERMIT Previous permit#
)New � _- Modification El 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 15A NCAC 6-2f YOO e 4 2 c
❑ Rules attached.
Applicant Name �rF' '� �� Project Location: County �(/` VO L"J
Address 0 -- ,/ Street Address/ State Road/ Lot (s)
City L) State ZIP ��7G� )y7 S-- 7
Phone # 6 E-Mail Subdivisi n
Authorized Agent �(y1 U `6yy!'� A 1/ C
El CW
�A
Affected
� oeA
AEC(s):
o HHF
� � �
❑ PWS:
ORW: yes / �o�j
PNA
yes /
City v� ZIP y
Phone # ( River Basin w ��
Adj. Wtr. Body �4f-4- 4' flC O74- (na unkn
Closest Maj. Wtr. Body
I
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Please
on back of permit"
Application Fee(s) ► CHeck #

Byc J
Page_ of
Date.

• • • i/�►� rr 1.•
Name of Property Owner Requesting Permit:
Mailing Address:
C1-+1A NC, a�uu
Phone Number:j')
Email Address:
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: R t LA fy) i 1n t WY)
1 f -�+ rucNIG w l �-i x, l 2'
✓ -,
at my property located at (�3 S —rr, S+. 5_,L 2-f CC+L,
in Penrt County.
l furthermore certify that / 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.
Signalble
>rt or Type Name
TWO
This certification is valid through ! !

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Pw i s
property located aty3� - n f�-C� me of Property Owner)
`,� r (Address, L _ Block, R , etc.)
on J Cy V in of , N.C.
(Waterbody) (City/To and/or County)
The applicant described to me, as shown below, the development proposed at the above
lopw4n.
1 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)
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 yo sh to ve the setback, you must initial the appropriate blank below.)
to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
ailing Address
IAA=telZip
ill'. mll .
Telephone Numbe /em it address Cd yn
lzi•nU.ig
Date
*Valid for one calendar year after signature*
MtCLW- t;� i -F-► ct,� CDT)() V\he rC,
Property,rner Information)
Print or
aili dff I�to�ss
1. l "1'ti-.� , N C_ a- € k-1 Lt
City/5tateMp
gI0,01 u-50&%1Z
Telephone Number/email address
(Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that 1 own property adjacent to b P -e G ' 0"v"y, 011 's
property located at -7 u 3 s- --I'�{, l' elk- (NeofProperty Owner)
(Address, ot, Bloc, Road etc.)
on , in U. -{ N.C.
(Waterbody) (Cityrrown nd/or County)
The Pp
ficant 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)
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 ou wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
i� I do not wish to waive the 15' setback requirement.
Information) (Adj#Eent Property Owner Information)
mr./W/A'�Naal
Print or Tkpe Name
-7U3K" _i �-
Mailin l�d ss C—
�; i9, #srare2ip7�` l OV4d
Telephone Nu r/ mail address
0q. ou •( q
Date
/ Print or Type Name
103-1 at"', 'b+RfC±
srlinq�lcw
citisrare2;p
fyx Telephone Arumberlemail afddrbss
Dy •01�. /9 _
Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature*
i r, cJ�c�►-fie_ wh�r� 6 a- -era h' q h "(gyt-�c�l
(v�.-s ' •' *
� �

Project _77Q 35 -7� �` 5-4 4 A , � 1 �.
�" BY r�.rrU
Subject pry y �_/�► r r a ( t Page �_ of /
CC

Data Received
Dab tad
Check From Name
Name of Permit Holder
Vendor
Check Number
Check
amount
Permit Numbe lComments
Receipt or Refund/Reallocated
Columnl
Column2
Column3
Column{
Column5
Column6
Co1umn7
Column6
Column9
/ —M
'Contal QWk & T
2191