72336D - Cameron

l /'❑ DR & FILI� V
ENERAL PERMIT
Alew Modification .IComplete Reissue El Partial Reissue
No 72336 A B C G°
Previous permit #
Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality hh u
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC VN �azv
/�/�� �j V Q CVO County
❑ Rules d.
Applicant Name / �IGt ' % Project Location: Coun N _ ..;
Address /
CityV State ZIP a Q
Phone # ( 0 ) / )Ja3 E-Mail �--•
Authorized Agent, &9/IM (CA61411
Affected ❑ CW VfW [JTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
ORW: yes / n0 PNA Xq no
StreetAdddress/ State Road/ Lot #(s) ` k
Sox
Subdivision
City <40y.- ZIP Sg_
Qj§W (IV ),539" WVL— River
-Baasin �, f���
Adj. Wtr. Body I JOIJI �' S C/,� ina /man /unkn)
Closest Maj. Wtr. Body aA
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10,
Agent r plicant Printed Name
Signature Please read comp lance statement on back permit
°= ,66f
Application Fee(s) Check #
Permit Officer's Printed
Nam
Signat re
� 5
Issuing Date Expiratio Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: (
Mailing Address: tP�FlX1,a �� 1 1
Phone Number:
Email Address:
I certify that I have authorized
0 Cl
0 - c�3ol-14uzl/—/ 1/0 - -04of
Wj P 4 " 1�cj Iq �) & A-6- - "
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
6"
at my property located at
in li"a4e 1 County.
I 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.
Property Owner Information:
Title
/ 8 cam
Date
This certification is valid through 61 1 �n / (�G k-)-&
�V'

property located at �� � �-
(Address, Lot, Block, Ro , etc.) uJ
on , in �! b'\�' N.C.
aterbody) (C' own arid/or C nty)
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, 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 setpack, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wisrto waive the 15' setback requirement.
IIIGIIIIII lIV VlG J /y
n AL 2s4uVl
CNIT01 'per 1 93Z
Tdiepho`ne umber
I M�;
Date
(Adjace t Prope er Information)
Ak
Signature
IYU p fi �s _ J 1! y N
Print or Type Name
5
6356 Qwni� Ad -
Mailing d ess L
i ,�ti��o,�,n/, 2�G4
City/State)Zip
Telephone Numb
/7Z?/11
Date
(Revised &1 &2012)
SCAB wa,�B Cc. fr -c Om

property located at (D`f 0 C-)
(Address, Lot, lock, Road etc.)
on elAi� Cl� 1 ���.� , in N.C.
(Waterbody) itylTown and/or County)
The app4icant has described to me, as shown below, the development proposed at th:dove location.
V. 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)
die, 1 16 � 444 L:4� 6,
ice.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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
thet sletb ck, you must initial the appropriate blank below.)
1 do wish to waive the 15' setback requirement.
�1 I do not wish to waive the 15' setback requirement.
(Prope O ner Informatio) (Adjacer►t' 1,Prope Owner Information)
r /
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Print or Typq Name Print r T pe Namp
tatli g Address Mailin Address
Z .m o
City/Stat ip City/Scat tp -r—
/ c Z Sl - Z � L,3 �j o - moo - 3!<_1
Telephone Number Telephone Nu ber
-zy -)y _. L
Date Date
(Revised 6/18i1012)

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Date
Dab Received 01poefted Check From (Name) _ Name or Permit Holder Vendor Check Number Check amount Permlf NumberlCommenta Recel t or Re(undlReallocated
_ Columnl Column2 C_ olumn3 Columrw _ _ Columns Colu_mn6_ Column? Columntt _ _ _ _ Column9
1/27/2019 Mar Jo Cameron same PNC Bank 666 $ 200 00 GP #72336D PA rct 7328D