Page, Phillip

..,,d CAMA / ❑ DREDGE & FILL N9
78485 A B C D
GENERAL PERMIT Previous permit#
LINew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality _ % / / `kX'
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
Rules attached.
Applicant Name
Address
City ^% C-1t State/fv ZIP
Phone # E-Mail
Authorized Agent
Affected ❑ cW ❑ EW ❑ PTA /[9 ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ 11H ❑ UBA ❑ N/A
❑ PWS:
ORW: yes f no' ' PNA yes'`,/ no
Project Location: County ) ^ I
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP
Phone # O River Basin /,/I/
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Agent or Applicant Printed Name I r
Signature Please read compliance statement on backof permit"
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Application Fee(s) Check #
Permit Officer's Printed Name j
Signat
Issuing Date Expiration Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to A • h a / ekq e— 's
/, (Name of Property owner)
property located at �UrI& fa%rx� eld Sneer/f /Y/�-y
-r_ AAddess, Lot, Block, Road, etc.)
on /"/"C e
r,
(City/Town and/br County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above
*�cation.
— t/ 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
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.
(Propperrttyy Owner information)
- 34 � Cr S z
.)-/- dD
Date
(Adjacent Property Owner Information)
Sign --Cn
Print or Type Name
(QC) s 'r: R V.1-^i 4aNr P pl .
Mailing Address
6Mc71ll5 �wPASt,Iy[ Z�ciLy
City/State/Zi
(�Bp 335-OtQtp�
Telephone Number/ email address
Z-(-%JZD
Dare*
(Revised Aug. 2014)
*Valid for one calendar year after signature*