74566D - Dowless

CAMA / DREDGE & FILL No. 74566 A B C D
GENERAL PERMIT Previous permit #
XNew ❑Modification ❑Complete Reissue ❑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 Roo
7 ,, El Rules attached.
Applicant Nan (C N / �. !� �� A11 �� Project Location: Countyi�—
Address �t/ /� U Street Address/ State Road/ Lot #(s)
City State ZIP
Phone # (lam) y' E-Mail " Subdivision
Authorized ent / Ci ZIP
■ ■
IVi ■ ■
Type of Project/ Activity
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cubic yards_
Boat ramp
Boathouse/ Boatlift
Beach
Other
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Name
✓f Permit fficer's Printed Name
A
Signature Please read compliance statement on back of permit
Application Fee(s) Check #
b. Y.I
Date
Expiration Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own party ro adjacent acent to +C.K W fs
Property located at Nu 2 6A 5 i �f}s5,+0 (Name of Property Owner)
-t,i sr O ili, c, 743
on i J�rT�La (Address, Lot, Block, Road, etc.)
(City(Town and/or County) N.C.
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)
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 setback, ou must initial the appropriate blank below.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Ow r Information)
zij= 2� .
Signature Signat re
�Y1lGfl,a-�� ,OOw[.�255 � �
Print or Type Name '
P nt or Type Name
Mailing Address
3 Mailing Address
City/State/Zip City/State/Zip
`7tU_� I ber -`i7�1 /
Telephone Num�/U Z Z 7
Telephone Number
Date
Date
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 10 v , 0 1 6 AiV oL 's
(Name of Property Owner)
property located at _y `y EA s ( 4,Q %FP S �.�
_ (Address, Lot, Block, Road, etc.
on -T i�C�A-STi}� in Iff�r��� /L.�:�' H�ii lillUA , N.C.
(Waterbody) (City/Town and/or County)
The licant has described to me, as shown below, the development proposed at the above location.
CI 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 setback, you must initial the appropriate blank below.)
/.� 1 do wish to waive the 15' setback requirement.
16
65.VIA I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Ad'acent roe "ner Inf rmation)
Signature gn lure
_ �(Xlf� '00 -kZs 52 0cl ilro j 1 k0b h -Q
Print or Type Name Prigto y Ne
�D (5 4ag n
ol��
Mailing Address Mailing Address
City/State/Zip City/State/Zip
Rio - S 12 S 7q/ '73 Z S 8'0 SOOS
Telephone Number_ Telephone Number
_ //V,s �/,- 5 -hr
Date Date '
(Revised 611812012)

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Date Received
Date Deposited
Check From Name)
Name o/ Permit Holder
Vendor
Check Number
Cheek
amount
Permit NumbeNComm M
Receipt or Retund7Reallocated
Columnl
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Column5
Column6
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Column8
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1017120191
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