72785D - Keever

CAMA / )(DREDGE & FILL
GENERAL PERMIT
FYNew ❑Modification ❑Complete Reissue []Partial Reissue
No. 72785 A B C
Previous permit #
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 0 O 0
❑ Rules attached.
Applicant Name s1MEs 9( ,1 1;M�1A[, Vrr_vER
Address 'Po L' o x 140
City Odc1 c>%P4-f State A/C ZIP 272Coi
Phone # (33y A4 Z - 3150 E-Mail colon;a 11%C . com
0
Project Location: County 1 R V,y Sw 1 C K
Street Address/ State Road/ Lot #(s) 1 2 7 & 12 q
LL,MRERT0 V STRr-Z-T
Subdivision
Authorized Agent ,ACKwAar- X MAR.tnrt;. City I \OLDJ7n4 'fFAC1A ZIP 217 4 (, 2-
Affected ❑CW DEW ❑PTA CXts Ctrs Ac-rc-Al7Phone # ( 910) 44S-4r98 River Basin Lt,'Mr?,rQ
❑OEA ❑HHF ❑IH ❑UBA ❑N/A CANAL
AEC(s): Adj. Wtr. Body gnat / a�� nT�
❑ PWS:
ORW: yes / o�l PNA yes / Closest Maj. Wtr. Body A W W
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CD IIELAIS
Age t or licant Printed
Signature Please read compliance statement on back of permit
it 4 o o -# I I I
Application Fee(s) Check #
-("yL_ER ► CCuirtr__
Permit Officer's Printed Name
" i"
Signature
2�25���Iq ��25�ot!4
Issuing Date Expiration Date

2/5/2019
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AGENT AUTHORIZATION FOR LAMA PrRMJT f,
Name of Property Owner Requesting Permit-. � I VN`A
Mailing Address C
Ell
Phone Number:
Email Address:
I certify that I have authorize,
A�+t�nt Gtz=�t„�tp•
10 act on my behalf. for the purpose of applying for and obtaining all LAMA;
necessary" for the following proposed develop,"j-ni: s i
at rr+y PrOl)Orly located At i
in i'flriiSl°tC IL Cnu. ty
rgeftttTJxr; r, r cettlly that r ar<> aut 'otiz ar? 1:) 9rtirrt, r ,
vi ron ��3 3 , astal lEA€ rtagttx rtf staff, the t�ocaf Permit of#tr�t�/
On 1'110 aforr�—f?ritfined lands to connection ih?th f'vf7#ild }; rtc7 t- .�jfk "i°?t.'tft3c`X h"> td;rs
a4U!117it wlaplrr"atfori,
https://mail.google.com/mail/u/O/#inbox?projector=l

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ':3aZmefs 's
(Name of Property Owner)
property located at I ZQ L41_mlyfhX, -5 .
(Address, Lot,. Block, Road, etc.)
on C(I-A" in '�� N.C.
(Waterbody) ity/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location. I, /
I have no objection to this proposal. re��QC� bj��h� a �w UGC lQx
"� bui'lCh d-
�L 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)
j�F 17�hw�-IJ�
tacit )eXis�► �c�1�1��aci ►� �Qrn�
WAIVER SECTION
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.)
T'\�71
1 do wish to waive the 15' setback requirement.
1 '-tt (2L— I do not wish to waive the 15' setback requirement.
(Property Owner Information) Adjacent Property Owner Information)
Signature Intur
14-d U/116diml�ld
Pr Type Name Print or Tpe'Name r,
/67n:z k i -r ha v d11S �-t�zSul 1d ���
M fling Address Mailing
City/ ate&Ji City/,^S�a/ /Zip
Telep one Number lemail address Telep one Number / email address
Date Date *
(Revised Aug. 2014)
"Valid for one calendar year after signature"

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent tos
1 (Name of Property Owner)
property located at �R16 /V
(Address, Lot, Block, Road, etc.)
on Nd LDE14 +30,oA eA/VflL , in I-V)1 Q� N 3CAC" N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatiop.
I have no objection to this proposal.
X 1 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.
l\ I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
Signature Signature *
TEO r
. Q :-) a 2 T LA Z LC I
.
Print or Type Name Prin or Type Name
1,11617 > 1?d z 2 ti ",/ h V) I i-C i� L,
MaiPg A dress Mailing Address
City/State/Zip City/State/Zip
916 - 11113 - c/ k 5 S �1, L-1- `MI5 -CIS,
Telephone Number / email address Telephone Numb r / email address
1- Z3-15 1� 2G ���
Date Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature"

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Defa Received
Date D.P..1tetlI Check From Name
Name of Permit Holder
Vendor
Clreck Number
Check
amount
Permit NumbffjU Mnts Receipt or Relund/Rcallocated
Column?
Columns
Column3
Col~4
Columns
Column6
Column7
Columns
Column9
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40000
GP 072785D
TM rd 7738