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Home My WebLink About72756D - Massengilla = CAMA / DREQGE & FILL NO. 72756 A B C -. • GENERAL PERMIT Previous permit# New ❑Modification El Complete Reissue El Partial Reissue Date previous permit issued As authorized by the State of North Carolina, Department of Environmental Quality '1 and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC ❑ Rules attached. Applicant Name A I1-)F /MASS t AJ6t tL L Address niC SO U74- City uy/ UGt %S State /yG ZIP Z- -S Zvi` Phone #204E-Mail Authorized Agent INN C7T M / C - ❑ Cw C�fW [X PTA -$d ES ❑ PTS Affected AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A ❑ PWS: ORW: yes / " % PNA yes Project Location: County NI-C> L O W Street Address/ State Road/ Lot #(s) jt 1. t✓� 2j't Subdivision City '�� r— C't 7 Lt ZIP G M45- Phone # River Basin Adj. Wtr. Bodyi'A v //0// 5. C'� (nat Closest Maj. Wtr. Body `✓✓U ig Sy "- ■■■■■■■rl1,!■i�■i:■■� ■�.7I%�i■i�i/■i■�Ifi[Ili■OME IMEME ■■■■■■■■■■■■■■■I■11■I11■■I■■■■■■�ilr■■[f, 7 r., r , ■■■■■■■■■■�■■■■ I ■1■i 11■H i■��n�■■■■�■■�■■■ ■■■■■iiiiil■■■_■_■III\I11! ��■�A�■_u�1■liii�i��■■■■■ ■■■■■■■■■■1= .Zimwi6.iainF1' w��...:■■■■■■■■■■■■ ■■■■■■■■■■I ■■■■[i i■■11i�■■■■■■I■■■■■■■■■■■ M. ■■��■■■■■ rmi�■■■■■■�11■dam■■■A■1[L■■■■■\■■1MW ■■ ■■■■■Witt■._■!:'!■■■1�.1111'��I1,�1'1[IIE1.1.11111�/■.R'■i^L�i4^�i;� ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ or Applicant #ignature "'Please -- d compliance stlteKent on back of permit'" �7-- AWfication Fee(s) Check # Printed Name Issuing Date - /9 Expiration Date AGENT AUTHORIZATION FOR LAMA PERMIT APPLICATION Name of Property Owner Requesting Permit: q /J,, • ./ � Lr455 E,UG t t L Mailing Address: 0f,o -41-C '?/, Jo ico4e,2- Ugks, .mac A Phone Number: 9l 9_ Email Address: CyeA-dZ4 I certify that I have authorized JU��A�gent�Contrac�tor��' to act on my behalf, for the purpose of applying for and obtaining all CAMA permits necessary for the following proposed development: I S at my property located at ��(� �„�� f Ci in _ p-P-�Q c R County. l furthermore certify that l 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: "--- Signature ii fl tiC �4 . -/&!5, s, N 61 L L Print or Type Name bcedi4e-2 �?7 / / a D i "�o/9 Date This certification is valid through I hereby certify that I own property adjacent to , �Y 's @lam of Property Owner) u property located at 3Lao t"a �1- C C, u (Address, Lot, Block, ad, etc.) on C1 �1 . inr_CIvl l_ (3e' N.C. (Waterbody) (CI own 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 ANDIOR 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.) PL,u I do wish to waive the 15' setback requirement. 1 do not wish to waive the 15' setback requirement. (Property Owner Information) (Adjacent Property Owner Information) SignaturAaJre s5'�y f�A+24RoYc— PHW or Type Name Print or T e Nam M R9 Adds ear iGS / �, a ZSa `)� Mailing Address •e 1J C_ at S .art-cl P � c rr o I rulD ri-% �,cA L-ps .COf-n TekVh� oneNumlYer/ema#address �'p Te/epl=eNumber ---fl iddress /--? /� `-;q as.113 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 to ,e _ u L s (Name of Proerty O er) property located at kr' psi` (Address, Lot, Block, Road, tc.) on I i • \;�`.1 in C.iCCU i N.C. (Waterbody) (City own and/or County) The applicant has described to me, as shown below, the development proposed at the above ioca ion. 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 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) Suture 'Z,�--)tip. /� �ASSEN6/G I- Plin or Type Nam Ma'tng Address t City/State2ip T I hone Number/email addres �1 y-Sao , t o q S' lti e tiri4o)X f�'sG• Co.►.� Date/ a0 _ `q "Valid for one calendar year after signature* Signat re* �du (�a.va h Print or TypeNarde ?b anx 47 Mailing Address RI. c-hlanLds roc 2gs7�% City/State/Zip Il()^ 215-5-Cf(o2 Telephone Number / email address I-a5--19 Date * (Revised Aug. 2014) G c 4 paw cno Date Received Date Deposited Check From (Name) Name of Perm/t Holder Vendor Check Number Check amount Permit NumberACemments Receipt or Retund/Rear/ocated Column? Column2 Column3 Column{ Columns Co1umn6 Column? column8 Co/umn9 2126r2019 Je Ennen/E—n Manne Construction Dian M kBirust 1d7' 00 GP p77 7