71790D - Herring

4ICAMA / DREDGE & FILL N2 71790 A B C
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 �� /O
❑ Rules attached.
Applicant Name W Project Location: County ±T }PEI) 13r Q_ _--
Address ' V 1 P L� L N Street Address/ State Road/ Lot ��-
City_ L d� 10 0 0� State .1C� ZIP Lk 6q l vF (,r,��
Phone #{� E-Mail —�� Subdivision
Authorized Agent N /
❑ CW
)<PTA ❑ ES ❑ PTS
Affected
AEC(s):
❑ OEA
❑ HHF
❑ IH ❑ USA ❑ N/A
❑ PWS:
ORW:
yes /. no'
PNA
yes 4S
city ZIP
Phone # River Basin (44—
Adj. Wtr. Body N IGS G#fkNf-EL-, (na mn
Closest Maj. Wtr. Body T?O IL_ 50v�'�
Type of Project/ Activity
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MEMENEEMMEEMEMENMEEM NEEL' iYANUE■ii
Agent or Applicant Printed N e
"Please read compliance statement on back of permit"
2/) G
Application Fee(s) Check #
�r C
Permit icer's Printed Name
Signat re
Issuing Date Expiration Date

ENT RIPARIAN PROPERTY
hereby certify that I own property adjacent to rn,,,' s
(Name of Property Owner)
orooertv located at / vim[ LLB
( ddre" s, Lot, Block, Road, etc.)
on AX4 Gf i�Gt K in Gc f4—'eX N.C.
Waterbody) t f6ity/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)
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 Owner Information)
Signature
Print or Type Name
Mailing Address
City/StatelZip
Telephone Number
Date
(Adjacent Pro erty Owner Information)
d
Si nature )
Print or Ty e Name
Di a �•Y,' n ti Tr� Dr
Mailing Addre%
2
s
G ltSl/, �C
atyl�sa
Telephone N ztuber
Dafe
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at
on
I
(Name of Property Owner)
(Address, Lot, Block, Road, etc.)
. in 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)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back a
minimum d tance of 15' from my area of riparian access unless waived by me. (If you wish to waive
the setbk,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.
(Property Owner Information)
Signature
I11)t�
Print or Type Name
�e f
Mailing Ad re s
City/State/Zip
of IQ - (7,nd
Telephone Number
Date
Date
Owner Information)
(Revised 611812012)

Date Received
Dare Deposited Check From Name
Name of Permlt Holder
Vendor
Check Number
Check
amount
Perrnif NumberlCommenfs
Receipt or Refund/Reallocated
Columnl
Column?
Column3
Co..
Columns
Column6
Column?
Column6
Column9
1 01
William antl Sharon Herein ' William T—Y Herein
t
166201
00
GP a 17
J rct. 7916