72796D - McCreary

CAMA / IX DRrDGE & FILL
GENERAL PERMIT
)(N4v --Modification ❑Complete Reissue El Partial Reissue
A B C �J
Previous permit N.
Date previous permit issued
No. 72796
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 079.1100
❑ Rules attached.
Applicant Name MC (5UPt-y VJE dT4..wjjL CIP►TAi_ LLc.
Address P6 13ox 13 o v '9.5 He
CFfARy
Ci zdie :wrpAj State IJC- ZIP 9-81, S 8
Project Location: County Z ¢,,AA! 5 IJ t c it
Street Address/ State Road/ Lot #(s) 1 2-1 '5
Phone # [phone]& q E-Mail b ►4 to- a &'r C rt c c Cc" Subdivision - -
Authorized Agent gA Ct4,,i A-rrrz _ Molcrn cor, S EAc N ZIP 2 $ (� $
�iAfi wr__ COwlf7p,�c�, LA.iJSGT
Affected ❑ CW ❑ EW ❑ PTA XES XPTS A&,r_ 'Phone # ( 910 ) 441 - 4?9 P River Basin LLtM ae ,Z
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ URA ❑ N/A Adj. Wtr. Body CA11AL- (nat an nkn)
❑ PWS:
ORW: yes / 0 PNA yes / Closest Maj. Wtr. Body K3 C Fz G-F V_
Type of Project/ Activity EP1/Ac-V- 1&w.y_o-tr=:A0 frl 7F_-ci5,,A/c, ALICiNMF_.*,jT
Pier (dock) length
Fixed Platform(s) _
Floating Platform(s)
Finger pier(s)
Groin length
number
ulkhead/ iprap length ± $ D
avg distance offshore 0
max distance offshore 0
Basin, c"Vnel
cubic
Boat ramp
Boathouse/
Beach Bulldozing
Other
Shoreline Length - 501
SAV: not sure yes 0--
Moratorium: /a yes no
Photos: yes (5
Waiver Attached: C)� no
A building permit m y be required by:
( Note Local Planning jurisdiction)
(Scale: 1 It = ZO 1 )
Sin NSF -r GrACt4 ❑ See note on back regarding River Basin rules.
Notes/ Special Conditions 0 r% A • %1 Ot.7 Al- O Pitt- •Di 4F—R (rCGA L 0 ,S r , 7'r.
Al-I0 1--r0r 12/EL RF—C-1ULA-`io,►s A-PALY-
vCh��+tr
Agent or Applicant P 'nted Name
Signature * Please read compliance statement on back of permit
$400 -t� II�'5
Application Fee(s) Check #
I�( m_ K cl G tz -
Permit Officer's Printed N
G
Signature
3/7 19 7 '1 11
Issuing Date Expifation bate

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Req
Mailing Address:
uesting Permit:
aIg
Phone Number:��-=.''�C�
Email Address F ' ` � . � m4e'rw .4
certify that I have authorized 77c-d Z r l'q-s ,
Agent / 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
in 6 .t 1 rkcounty.
1 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.
Property Owner Information:
W?E"V0411'11
Signaturg-
177 qaejr.
cc�
Prin or Type Name
- 9A d°�-
Title
Date
This certification is valid through l_1Z9

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent tokS�reCLn,4s
-� (Name of Pr erty Owner)
property located at io� l� CG.n� �Jr
/' I (Address, Lot, Block, Road, etc.)
on c nu -I , in �S tnse-i- Read, 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, 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 '�'J — -7s') I do wish to waive the 15' setback requirement.
tl
`/lL, I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Sty atur
7t
Print y eName
�f' r
Mang Address
Cit elw8
I
Telephone Number / email address
Date
(Adj
ner Information)
Sig
Print or Tye Name
��13
Mailing Address �J✓
_-
CityiSfatZ��_
Telephone Num�er / ejnail address
//10/i 9
Date*
(Revised Aug. 2014)
'Valid for one calendar year after signature`

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
A.
❑ Agent
B. Received by (Printed Name) C. Date of Delivery
D. Is deliAry address dfff&rent from item 1? ❑ Yes
If YES, enter delivery address below. ❑ No
on QboYl2A .
�Crlr riSburc� f t�C Abis
3. Service Type
❑ Priority Mail Express®
❑Adult Signature
❑ Registered MailTM
II
I
I III
III
II
I II
IIII
I
II
I III IIIII
I
III
❑ AIf Signature Restricted Delivery
Mail®eglvery
❑ R stared Mail Restricted
9590 9402 3999 8079 6846 99
ertified
❑ Certified Mail Restricted Delivery
'Return R. pt for
Merchandise
❑ Collect on Delivery
❑ Collect on Delivery Restricted Delivery
Mail
1:1 Signature ConfirmationTM
❑ Signature Confirmation
2. Article Number (Transfer from service label)
7 017 0190 0001 1320 5430
Mail Restricted Delivery
nn)
Restricted Delivery
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to —&n tAc F- P\(Z\� 's
(Name of Propert Owner)
property located at 17 i J� A N A 1— Z SU NSE T �CA-C"
(Address, Lot, Block, Road, etc.)
on Li-N kL in Su Q SET- E&-ctt N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loca . on.
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)
SEE �) 12frwTN&
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.
(Property Owner Info ation)
Signature
Print or Type N�am,-e
�C1�,o i is ms�/ /Cw
Mat ing Address
City/ tate/Zip
f0-W3-y �
Telephone Number/email address
A 2S is
Dale
(Adjacent Property Owner Information)
Si a it -e *
I o name—r Nark C� Ira vtf
Print or Type Name
'2- o�,y me atcoc4--, L.a w--
Mailing Address
i i In � Zg�i e
City/State/Zi
Telephone Number / email address
p2 ICI Ig
Date*
'Valid for one calendar year after signature"
(Revised Aug. 2014)

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
I. Article Addressed to:
20Zy
W f i (Kj
,
A. Sig ure
�.
X T�-' r�gerR
❑ Addresaraw
by (Printed Name) C. Date of
Is delivery address different from Item 7? �] Ye;
If YES, enter delivery address below: ❑ No
II I
IIIIII
IIII
III
I II
IIII
I I IIIII
II I I II
II I
I II III
U. Adult Type
❑ Adult Signature
❑ Priority Mail Expresse
0 Adult Signature Restricted Delivery
❑ Certified Mail®
❑ Registered Mail-
❑ RRe�i�very� Mail Restricted
�. Article Number (transfer from service /abeQ
❑ Certified Mail Restricted Delivery
❑ Collect on Delivery
❑ Collect
❑ Retum Receipt for
Merchandise
7 018 0680 0000 7028
on Delivery Restricted Delivery
4230 i
❑ Signature ConfirmationTm
❑ Signature Confirmation on Very tion
Restricted Delivery
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt ;

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Date Received
Date De oeited Check Fmm Name
Name of Permit Holder
Vendor
Check Number
Check
amount
Permit NumbenComments
Receipt or RefundIRBSIWcated
Columnl
Column2 Cotumn3
C.1-4
Columns
Column6
Coltenn7
Column#
Column9
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