72808D - Cameron

tr CAMA / DREDGE & FILL No. 72808 A B C
GENERAL PERMIT Previous permit #
INew []Modification El Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality O L�•-} O O
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC ` 0
❑ Rules attached.
Applicant Name `q Project Location: County/(...
Address 1 e O / n Street Address/ State Road/ Lot #
City " State N� ZIP-0
Phone # � Z ' 550 E- ail Subdivision_
Authorized Agent �� �%C� CityfflfAZIP 2
EW1 PTA ❑ ES ElPTS
❑ HHF El IH El UBA ❑ N/A
❑ CW
Affected
AEC(s):
ElOEA
❑ PWS:
ORW:
yes no
PNA
yes / no
Phone # ( --��' River Basis• ' .11�
�'! � -
Adj. Wtr. Body � w C nat unkn
Closest Maj. Wtr. Body
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type of Prollec.-T.1,
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Ag nt or rinted Name
Signature ** Please read compliance statement on back of permit **
Application Fee(s) Check #
VrI1
Printed Name
Issuing Date Expiration Date

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Properry Owner ApplOng for Permit_
V iw) C, -z;4
Mailing Address- fj
I certifv that I ha%e authorized (agent) to act on ntv
r'
behalf, for the purpose of applying for and ah/tainin all CAMA Permits necessar'. to
install or construct (actisity) t�� 'l(// Aer
:it 4niN propem located at) �J� •� /�f r//i 17L Z 0e,/ /ed1
/ l
This certificatinn is valid thru (date)
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to _�1/ Cj�Cty°Cl f s
jf pme of Property Owner)
property located at
_ (Address.
on
__ in
(Waterbody)
:k, Road tc.)
(CityITown 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 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. (it 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_
Prim cr f y'x N,,mt,
M•�r! Address
Cr±y zin
TElBF?fiOrl�rRbEi', errati' ad'rESS
-Valid for one calendar year after signature'
(Acl�acettt Propa+rty Owner ��brrs,>N
OnC,me4
Pnnt,)r.i ,ve NarnA .
14far . drkess
z.a z9
Telephone Number /t-mail address
(Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
a
I hereby certify that 1 own property adjacent to 1 G'11 s
Name of Property Owner)
property located at
(Address, Lot, lock. Road�tc.)
on %3/l4L�; _ in �f �Tl-u . N.G
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location, /
y 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)
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' setback requirement
TeiWorte Num¢er ernad address
�r Type .14 r
rd:y� Address
Tereat--mv Jurlss
(Re vised Aug. 20141i
,Va♦id :or one calendar year after signature'

r 6umnW.'ail
3�rz loor
�r
6)9c &fn)avf4
C - dUr

Date Received
Date Deposited Check From (Name)
Name of Permit Holder
Vendor
Check Number
Check
amount
Permit Number/Comments
Receipt or Refund/Reallocated
Columnf
Column
Column3
Column4
Co1umn5
Column6
Column7
Column6
Column9
/11 r2019 �
Pi in Man- Construction LLC
Ga C.— n
I WOFaro Bank
5003
00 00
GP #7260
7766