72738D - Kennedy

4CAMA / ❑ DREDGE & FILL
GENERAL PERMIT
4aNew []Modification El Complete Reissue ❑Partial Reissue
No. 72738 A B C D
Previous permit #
Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality �j ��
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC / /T, 13 60 d �
❑ Rules attached.
Applicant Name R C: I / A kC /Y-we—� /
Address 16 � Ile", & n/ T /` �-
City 119syd 5 7e,41 (1 State_AIC ZIP 2
Phone # (�2Q) - G O E-Mail'��h i.✓c d6� eC. F�. C6�*
Authorized Agent V o I ey),- e
Affected ❑ CW rAW gkT'A OS SOTS
AEC(s): ❑ OeA HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
ORW: yes / to PNA yes / o
Project Location: County �[c,
Street Address/ State Road/ Lot #(s)
5 A,e2
Subdivision
City
Phone #
ZIP // /
River Basin 44, ,V 4�J
ie
Adj. Wtr. Body /�/ by (nat /man /unkn)
Closest Maj. Wtr. Body
A ill, 1111111
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Agent licant Pr' d me
a-
Sign ture*+ Please read compliance statement on back of permit
/ f�fl ✓ �� ��
Application Fee(s) Check #
pPAwoo w+1s, ,
Permit Officer's Printed Name
Signature
Issufng Date Expiration Date

. W
AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:�i1 �w
Mailing Address:
Phone Number:
Email Address: k., f, ! , DID ec , rr , �m
I certify that I have authorized
/ Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at kl
in Lf &gf CLI County.
I 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.
Owner Information:
r
Signature
Print or Typ� Name
dwnec
Title
1 I
Date
This certification is valid through I l

ADJACENT RIPARIAN PROPERTY OWNER STAT MENT
I hereby certify that I own property adjacent to �` f � ., L is
property located at
(Name of Property Owner)
� �-„� ��� n`>� ,�
'rAddress, Lot, Block Ro d, etc.)
on ins--r.- , N.C.
(Waterbody) I (CitylTown 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.
1 have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in descrip>yon below or attach a site drawing)
WAIVER SECTION
understand that a -pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back a
minimum distt?y area of riparian access unless waived by me. (if you wish to waive
the setback, -initba '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 Information)
Signature (l Si ature
Print or Tye Name ti Print or Ty N me 11
r �G�eP �oiNf �,d•
M ding Add=ss
Ma' . g Address
rn r _ ct w� e KG 2-24 �F3
City/St e2i Ci /State2
p 91 � p (0Z0 - "O(o5
Telephone Number Telepnne Nu ber
I o
Date Dare
5U Sa nne fivm phriry
CpylaaS it
efost n

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ar44

Dale Received
Date Deposited Check From (Name)
Name o/ Pemit Holder
Vendor
Check Num6ar
Check
mount
Perm/t NumbenComments
Receipt or Relund/Realbcafed
Column?
i
Columnl Column3
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Column/
Columns
Column6
Co1umn7 Columns
Co1umn9
3r2512019 Valentine Construction K M Kenne —:TD Rg,k
60000 GP#72730D7