74297D - Gawron

CAMA / DREDGE & FILL No. 74297
A B C
E N E RAL PERMIT Previous permit # °
New Modification El Complete Reissue El 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 I SA NCAC
^, ' n ' vi'l Rules attach
Applicant Nan Uir ' Y L-1 A 1U v V ly y ` Project Location: County y nA �
Authorized Agent
Affected ❑ CW - EW �TA El ES ElPTS
AEC(s): ❑ OEA HHF ❑ IH ❑ URA ❑ N/A
❑ PWS:
Signaturreej� ** Please read compliance statement on back of permit
Application Fee(s) Check #
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP
Phone # ( River Basin
Adj. Wtr. BodyQ�4kl LOA 'N
nat /_ an /unkn

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
I----\\
Name of Property Owner Requesting Permit: 'J O'Xcy ee - G-C4tis (-Q n
Mailing Address: 1 5 q ptc;,r AJ yu,p S d (-•
AJL DS'/6
Phone Number: l 16 - 9�� / 1MZZ
Email Address:
I certify that I have authorized (eZ io
Agent / Contractor
to act on my behalf, for the purpose of applying for and obni taing all CAMA permits
bt
necessary for the following proposed development: I'' i e,( Id
at my property located at 106 C�et�kn
in??(Ur\Sw'&K County.
l furthermore certify that 1 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:
i
x
Signature
Print or Type Name
itle
01116 1 a°/ 9
Date
This certification is valid through -1 / 1 161

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to aiif'675 �,pG/�q/y s 40
property located at Q15 vg
n_ _Yl_ (Name of Property Owner)
�
n (Address, LotAlock, Roa , etc.)
on ,C/�t'%l3�%i1 �,2F�3C , in �Ourp-}R��'T N.C.
(Waterbody) (CitylTown 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, 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 ner Info ation)
4"&
0 01T�4 0,4 e
nature
Print or Type Name
M ' ing Address
City/StatelZ
wo - q7�-Osc �
Telephon Nu ber
oy ao/9
Dale
Information)
Filgr
Print or T e Na
02 t to �DICa s �2
Mailing A dr s
SOv '6
Cit /Sra, e
TeleNum r
Date /
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to tv/(U(1 s
property located at f! lj (Name of Property Owner)
���s Dr, 0
Creep Address, Lot Block, Road, etc.)
onDL�JChMG� in r N.C.
(Waterbody) (Ci /Town 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 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, 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.
(rier In rmation) (Adjacent Property Owner Information)
,Prope4rty,,,
i ure
'�
Print or Name Proft or Type Name
M ' ' g Address Mailing Addre s
6,e7-) Ir/C %6/ 41 a f-.L, r
City/ tate/Zi City/State2rp
/ 1 P/7%—d 3 0 17 i o --
TelephonQ Num r Telephone Number
Date Date
(Revised 611812012)

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amount
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