Kucich, Michael

XCAMA / El DREDGE &FILL N. O
78484 A B C D
i !�, GENERAL PERMIT Previous permit#
New ❑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
,+� -Rules attached.
Applicant Name T'i F' I ` 1 1 / ( Project Location: County (/ I I
Phone #
E-Mail
Authorized Agent
Affected ❑ CW .-MEW -L�7 PTA
AEC(s): ❑ 0EA ❑ HHF ❑ IH
❑ PWS:
ORW: yes / no PNA yes / no
I +IC` � Street Address/ State Road/ Lot #(s)yFT
e�ZIP ✓7(/(
_�— Subdivision %
i
Cit)t ZIP
❑ES ❑PTS Phone # ( ) River Basin
❑UBA El N/A I i
Adj. Wtr. Body ' � t � '(natNman /unkn)
Closest Maj. Wtr. Body —
Type
C,
Agent or Applicant Printed Name Jf/ PermltOffcer s Printed Npriie /
Sign ure•z Please read compliance statement onbackofpermit" $ig�t
Application Fee(s) Check# Issuing Date 'Expiration Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to N E (-Er' wA LTo,J 's
(Name of Property Owner)
property located at OAL� A'z'1 v u t:. �4 wo
(Address, Lot, Block, Road, etc. '
on /�/��1�t�c Crieq� in Srvwt/S �h�s/ . N.C.
(Waterbody) (City/Town and/orCounty)
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)
I
d
'Seta wa,'
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.
f I do not wish to waive the 15' setback requirement.
(Property Owner Information)
(Adjacent Property O nne Inform/a�tion�)
Sign turg
/✓�t�l �K�FL >� l/uu l-/
Signature
HeLe
c
i IJA CFJ^�
Print or Type Name
Print or Type Name
I I q 04e 1A"-e
13- ) OAL' Lo,t&
Mailin AddrefJ�s / �/ 'J
�lwxc/J /`i �/i
Mailing Address /��
SN94�S i. C7
✓��
r W01 rJ !r'I�Q
City/St 11_ � - 7-79
!
City/State/Zip
Telephone Number
a-s-J0�b
Telephone Number
Date
Date
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to !/off w C-?r 7 A('Jel / 's
(Name of Prooertv Owner)
property located at
Li/�e ��� C��� / (Address, Lot, Block, Road, etc.)
on t tf n SNoclS AAwl N.C.
(Waterbody) (City/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 fill in description below or attach a site drawing)
o
v�'1111ar � t'.unl
(z(047iaj/ oa. 04F�
oou6 `��y
n
'07
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.
yI do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
z2 rc A-14L, �✓ �LrCIG E�
Print or Type Name
C/ �
Mailing Address
S"1\N?Ac1S o�na29/ n/cc/Cc c�
City/State/Zip
'�'t 9 - &�S- 774/
Telephone Number
Date
(Adjacent Property Owner Information)
Date
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2
(Revised 611812012)