74752D - Foreman

ICAMA / DREDGE & FILL No. 74752 A B C Q
GENERAL PERMIT Previous permit #
-New iModification Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality /,
and the Coastal A s urges Commission in an area of envviiro �n�Lconcern pursuant to I SA NCAC Al f�. 12 0
10,5
, ❑ Rules attached.
Applicant Name (/a �v �a� l�If/l 0 v/ �v/t l/ Project Location: CountyWl�'JC11�i1'
Address CIrl & 46 T to x Q 3
City AV AE W?b s
Phone # (r q —6//-44? 5 Maill*([o,P 40"'Aux' I.
Authorized Agent 9 W a 4 iFo- m4"a i
Affected
AEC(s):
❑ CW XEW .19PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit
2 0�'- 9 '�4
Application Fee(s) Check #
Street Address/ State Road/ Lot #(s)
�'s %� omot br'(W
M')Subdivision City ✓( Ogg
g40
ff
Phone # ( ) River Basin (mil
Adj. Wtr. Body lei (ACT A t r an /unkn)
Al 1.//,
�-H.1 L�(l, ,...
rm Peit Officer's Pri ed Name
Signature
/Q120(q 4/g1201�
Issuing Date Expira�on Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 44A R C-n L- - V ,lq I-- 104N D o
Mailing Address: C ZL( R -7- 3 nx,- y6 _3 5
_4 too .9 0909
Phone Number: 6 0 <49 - (0 r r - Z/ y -7- 6-973 9D
Email Address: _ )4-lao-c-o , e, v i c►_. (to a n Jo - c i v C Mq t' 1• �+ i i
I certify that I have authorized -S-�Uar JL F re-M a * t C/"%ft re fcw,
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: poe"k 2! X
at mypropertylocated at
(V5 PC �G�•� D/ 1i(�r4f�(/i'l�C �CuG�
in c w PU-V✓tr County.
i furthermore certify that I 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:
Signature
A44Mcc L::- , v1.4J-- tOIq AAaa
Print or Type Name
CA" ep O F S t� �-.� �� ! '+ r
Title
A D I `� I 9'
Date
This certification is valid through 1 I

L
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
! hereby certify that !own property adjacent to %yo/Co �� 1/ iI /
---. - -
�, r , (Name of Property Owner)
property located aton
r
(Address, Lot, Block, Road, etc.),_,
(Waterbody) ' (City/Town and/or County)
The applicant has described to nee. as shown below the development proposed at the above "tion
have no objection to this proposal
gave objections to this proposa:
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
jlndividuai proposing development must fill in description below or attach a site drawings
WAIVER SECTION
i understand that a pier, dock, mooring pilings, breakwater, boathouse I!ft or groin must be set track a
minimum distance of 15' from my area of riparian access finless waived by me Pf you wish In wave
the setback you must initial the appropriate blank below
I do wish to waive the ' 5' setback requirement
_ _--- I do not w+sf` tc
waive the 15setback requiremew
(Property Owner Information)
(Adjacent Property Owner tiitormation)
(fre t4qeo�
0^
.�1•N,lttltilt't'
,��1,{�riill7t?'C ,
print o,•- type Name:
,In! or Type fvarno - ---
Mailing Address
iA alwiq/Addre.5s
City/StateiDp
CityiState4zr
Jt
_
'e+ephor+e NumhF,
Telen one Numbe-
%tail'
OWE
I'ReIse.'.' fCl 6120 i 2'

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Agrcn F s
ff�' l/ 1�r (Name of Property Owner)
property located at
on E�� S C. I ct- (Address, Lot, Block, Road, etc.) _
in _-1I V C4A, �, . �✓ r N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above location.
X I have no objection to this proposal.
1 have objections to this proposal.
ut:SUKIPTION 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.)
_ I do wish to waive the 15' setback requirement.
X I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
Si,�iiatrire
Print or Type Name
Mailing Address
City/statelZip
Telephone Number
Date
Signature
Sharlene R. Williams and/or A
Print or Type Name
26 Pelican Drive
Mailir�p ddrg$�
Writ] sTiMe Beach
City/State/Zip
North Carolina 28480
Tetg+i�}q`I el �iY�ber
Date -- - - -
(Revised 611812012)