72896D - Hull

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CAMA / '❑ DREDGE &FILL � � No. 72896 A B C
GENERAL PERMIT Previous permit #
ew El Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality �� n v
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC I
�f ❑ R s attached.
Applicant Name -V !/ ) LLO Project Location: County �! A 7 G..�
Address
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City V •�
State /c- ZIP
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Phone # ) i S
E-M H
Authorized Agent
ti ✓ ��
Affected ❑ CW
\ZDFW ❑ ES PTS
AEC(s): ❑ OEA
❑ HHF IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / 1 - )
PNA yes / no
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Street Address/ State Road/ L;V(s)
�j
Subdivision
CityZ V ZIP 2 y S
Phone # River Basinht4 e G�
Adj. Wtr. Body Z�_44-, r d� v e � C . ^ unkn
Closest Maj. Wtr. Body
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e or�pplic�nt Printed Name
i
Sign-, re * P ease read c pliance state nt on back of permit
<�
Application Fee(s) Check #
Printed
Nigna e
y_ �� �41 7 /e ~ 1 I
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERNIT APPLOCATION
0
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
Z
I
�DV-4 16 5(A)) VC/-,hoo. 1�011—
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CA/MA permits
necessaryfor the following proposed development..
. 9P p P
at my property located at
in I� County.
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1 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
Print or Type Name
L't'v- ,
Title
Date
This certification is valid through ) I

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �G�vu� -�`� �t 's
(Name of Property Owner)
property located at ? 9 Z S
(Address, Lot, Block, Road, etc)
on CA+n�-1 , in 4- C - N.C.
(Waterbody) (City/Town and/ r 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)
C
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 wi h to waive the setback, you must initial the appropriate blank below.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Pro erty Owner Information) (Adjacent roperty Owner Information)
i,gnature C! Signature
i �)OrlsC
Print or Type a ( Print or y e e
QVV2 S?
Mailing dress Mar ' d ss
C49sGl J D � � �� V S I COY/ te2i I /
Tel hone umber/email address Tele he ,u ber/e ail address
Date Date Iq
'Valid for one calendar year after signature' (Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY oWnC" J'1- '
certify that I own property adjacent to (Name of Propeti rty Owner)
i hereby S
property located at �- f /
(Address, Lot, Block, Roadetc) N.C.
c,,,..�
on `"' l in (Cityn own and/ r County)
(-aterbody)
The ap 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
l osing development must rill in description below or attach a site drawing}
(lndividua Prop
i:A1V CR .7Gv
I understand that a pier, dock, mooring pilings, boat ramp, breakwater; boathouse, lift, or grain
must be set back a minimum distance of15'from my rea of riparian
the appropriate blank beto unless waived by
me. (If you wish to waive the setback, you must initial
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
signature C /
� t
Print or Type r►� s
Mailing dress
City/Stl i azIp
D
Telephone Numbber/email address
Date
(Adjac,ont
/
Owner information)
Sign ure
I (-V,C'
Print or Type Name (�
-7c"(Ll
"'4)1, EMLl Ce.
City/Siate2ip c' 0 . � � 6. NV
V
Telephone Number/email address
ri_ir_% - A
Date"
`Valid for one calendar year after signature'
(Revised Aug_ 2014)

Date Received
Date Deposited Check From (Name)
Name or Permit Heider
Vendor
Check Number
Check
amount
Permit Number/Comments
Receipt or Rerund/Reallocated
Column,
Column2 Co1umn3
ColumM
Co1-5
Co/umn8
Column7
Column8
Column9
3/18/2019 Li hthouse Manne Construction/David Hull David Hull Coastal Bank & Trust 2610 $ 200.00
I GP 72896D JD rct. 7985D