74621D - H&M

CAMA / DREDGE & FILL
GENERAL PERMIT
New ❑Modification ❑Complete Reissue ❑Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resourcgs Commission in an area of environmental concerp
Applicant Name I
Address L,4 `N 6
City 0© State ZIP
q
Phone # �Z) W � lE-Mail
Authorized Agent
Affected ❑ CWW PTA ❑ES UPTS
AEC(s): OEA HHF IH ❑ UBA ❑ N/A
PWS:
ORW: yes / no PNA yes / nod
No. 74621 A B c //
Previous permit #S.
Date previous permit issued
n-) 1
Pursuant to I SA NCAC 0I O "
E411ules attached.
Project Location: County
Street Address/ State Road/ Lqt #(s)
Subdivisign
City vit F zip
Phone # River Basin
Adj. Wtr. Body UW A . i �G nat m n__kn)
Closest Maj. Wtr. Body
Type . Fixed Platform(s) 1 Pier (dock) length
.■....■■..■■■..................■■■`_;1■■
distance shore
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■Li■■■11%r■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
M. ',�I
.� .
■EM■ME■■■■■■■■■■■�■■■■■■■■■■■I�■■■■■■■
All
MMEMMMEM
■■■■■■■■■■■■1/■\I�I�EE�■■■■■■■■■■■■■■■MEMO
■■■■■■■ ■■■EI■■■■■■■■■■■■■■■■E■E■OMO■■E
■■■■■■DIEM■■■I ■■ ■�■■■M■ i1■■■■■■■■■■■■■■
■■O■■Oily■■■SIG�i%Eii■riE■��ILM■O■OOP■■■■■
t or Applicant Printed Name �-
Si re Please read compliant stat ent on back of permit
Application Fee(s) Check #
-VV
__P-ermit icer's Pr ted Name
natu
/o.zy /,�
Issuing Date Expiration Date

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 Owner Information) (Adjacent Property Owner Informatio )
Signature Si lure's
r
Print or Type Name PrintZr Type ame
vim" C/ �� IN —)}�
Mailing Address Mailing Address
CitylStatelzip CityA ate2i0°-�
Telephone Nurrjber/email address p
Telep one Number/email address
., f
)c�Ct
(Revised Aug.01 a1
"Valid for C"e calendar year after signature*

Dare Received
Date Deposited
CMtk Frwn (NonNama
of iWm/t NOAW
Vwvdor
Check Number
Check
unt
Permit Numbe lComments
Receipt or Refund/Reallocated
Columns
Column3
Colrmm3
Colu-4
COlumnS
COlumn6
C0k 7
Column8 _
Cplumn9
1025=19
10/252019
Carolua t3ulWl Co
Summer Rest LLC
First Sank
1400
200.00
GP N74753D _
Tmc rct. 8289
�JD
k and Trust
2903
s 20000
GPO746210 rct 8541