73531D - Gordon

CAMA / 'XDREDGE & FILL
GENERAL PERMIT
pew ❑Modification ❑Complete Reissue ]Partial Reissue
No. 73531 A
Previous permit #
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 I SA NCAC 07 1100
❑ Rules attached.
Applicant Name al< CW pA C'1 oRUo N
Address 14 1 3-rAP-FIs N DR
City µoupr_,4/ Gr-AcA State_Atir ZIP 2 94 b 2
Phone # (74+ SO` - 0315 E-Mail �6rendader- ®,coi,cor•. Authorized Agent MALK Cox
Project Location: County EsL&,MSiLJIcy.
Street Address/ State Road/ Lot #(s)
Subdivision
City
ZIP
31 O,
Affected ❑ Cw ❑ EW ❑ PTA 9ES XPTS AAEm-t Phone # (5-,) fi20. 9 3 o4 River Basin
❑ OEA ❑ HHF ❑ IH ❑ UBA El N/A
AEC(s): Adj. Wtr. Body CANAL (nat man unkn)
ElPWS:
ORW: yes / CID,PNA yes / � Closest Maj. Wtr. Body A 1 W
Type of Project/ Activity k EPLA c-e- L3 W..KNEAn ►a r—io sTmict U GN MIle- A/T
Pier (d�at
length
Fixed Por
Floating Platform
Finger pier(s)
Groin length
number
ie iprap length So
avg distance offshore Q /
`` max distance offshore -
Bain, channel
Boat ramp
Boathouse/
Beach Bulldozing
Other
Shoreline Length 5
SAV: not sure yes (no
Moratorium: (9 yes no
Photos: yes 0
Waiver Attached: p
no
A building permit may be required by:
( Note Local Planning jurisdiction)
(Scale:1 '1 : ?U'* )
❑ See note on back regarding River Basin rules.
Notes/ Special Conditions n ry A. (l % no 71 ALL 011AE L LOCAL-0 S TAT A," b
571=DF_RAL. GF—G "%- A11QAfT -APPLY.
&Pry�n - (nor_j on
Agent or Applicant Printed Name
igna ure * Please read com ian statement on back of permit
i}o0 *-- 1 &3
Application Fee(s) Check #
Permit Officer's Printed Name
C
Signature
54 A2o19 9 1 2019
Issuing aD a Expiration Date

AGENT AUTHORIZATION FOR CAMA PgRMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
St
LA I'
M-0 ,r k.
Agent /Contractor
ON
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: r�� _ ' (�'� L`-
U
at my property located at t 4( S- lr Vs L
in'4�c— 1c, );Ck. County.
l furthermore certify that l 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:
nature
Print or Type Name
Title
l 4 1 I
Date �T
This certification is valid through I

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �nja (��(Jo j a m �blt N 's
j (Name of Property Owner)
property located at t 4 l s�r q,�
(Address, Lot, Block, Roadetc.)
on �G VIat , in &0-flA OC14, , N.C.
(Waterbody) (City/Town and/or County)
The app i.cant has described to me, as shown below, the development proposed at the above
locati
` 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)
16ul k UL a) 'Ym Locr-��
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. ( u 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.
(Property Ow er Information) (Adjacent Property Owner Information)
n e Z1A�kj
(:-,Dr
/ftPXM6n ���n �l l C��� �- • J�`�7L� ' N� .�
Print or T pe Name Print or Type Name
[41
MAM fling Addr� t�C�2�Z Mailing Address
N. J;A 6i:i Awl 01 -19 I V'A 2-i'ZZ-7
City/State/Zip Ci /Sta e/Zip
-4n� , 920, D?-)l s l �Y�. ee(�aa/,fin Ap (5� t 4lc�-
Telephone Number/ brVail address Telephone Number/email address
q ,LEI 1-a) 4 Z I �%/
Date Date *
(Revised Aug. 2014)
*Valid for one calendar year after signature*

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �- VI(^ �tCY1Mot) M,
1 's
r�� `(Name of Prope Owner)
property located at `� ��-1�-
��tt�� ,�,, nn Address, Lot, Blgqc�k��, Road,
on LS-t��C. in l aC.�eCLC,',, N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
Ielca ion.
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 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.
(Property O er Information) (Adjac nt Property Owner I formation)
Signature VIture
Print ( r Type Nan Print or Type Namji��
Ma'' I�to� A�-- ddress Mailing Address,
N /� 284(,z �c'M 4G
3L�f' Jae,O3fS_elZip/ I City/State/Zip
P u(.Y lv
Telephone Number/email address Telephone Number/email address
Date Date l
Gvv t � ��T C;-- �AI
(Revised Aug. 2014)
*Valid for one calendar year after signature*

M
o _-
C�bt�k�
kvou �-ON --Y
lok LZ
bcc,
--J�q N
C ' 7)
31z;raN
../1— ►10) ►g
l�
MSS ��\

Date Recelved
Dab Dopositod Check From Name
Name of Permit Hoklw
Vendor
Check Number
ch.�k
amount
Pol Wt NumbenCommenb
Racel t w Rahal&Wea9ocated
Columnl
Col-2
Column3
C.1-14
Columns
ColumM
1 Column?
Cok."
Co/umn9
bH
1
P