66149D - Marsh

❑LAMA / ❑ DREDGE & FILL
A B C 6D
GENERAL PERMIT Previous permit #
New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources —') f j '1 ( (�
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC (�( �` V 4
El Rules attached.
,,
Applicant Name ) �V✓f Project Location: County W1,
s 1 u 0' V-6 UI r Address i � � ��� Street Address/ State Road/ Lot #(s)
Ci State A ZIP�C, ! V ' I,+t1i`, U'�r ,L1 .
Phone # (
)
-Mail
Authorized Agent
11
❑ CW
PTA
Affected
AEC(s): ❑ OEA
❑ HHF
❑ IH
❑ PWS;
ORW: yes / , no
PNA
yes no
Type of Project/ Activity
Pier (dock) IengtO '^ ko I x- 1
Fixed Platform(s) , X k(
Floating Platform(s)
Finger piers)
Groin length
number
Bulkhead/ Riprap length
avg distance offshbre
max distance offshore
Basin, channel l/
cubic
Boat ramp
Boathouse/
Beach BullAozin
Other MOW
AI i 0�
shoreline Length
SAV: not sure yes
Moratorium: n/a yes (
Photos: n
Waiver Attached: yes
A building permit may be required by:
( Note Local Planning Jurisdiction
Notes/ Special Conditigns
Pigent or
* r
1 ( Subdivision
Oqu
City ZIP,��
❑ ES ❑ PTS Phone # ( ) River Basin
❑ UBA ❑ WA Ad'. Wtr. Body—
Closestr .ram, (nat Oman /unkn
l)
Maj. Wtr. Body `fLI V v
Please read compliance statement on back of
Application Fee(s)
(Scale: Ii )
❑ See note on back regarding River Basin rules.
r :fA �' I Ul �A Yl VU V
=!'fin y` VA .� � N't
Permit Officer's Printed Name
ermit—�� Si naturr5, A,
Check# I uing 4to &piratnbate

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: v (ti e � M n n " e " mas�
Mailing Address: I q�o f, o r L Pd
Marsh v I' I I :, k/C al 0 3
Phone Number: jpd- AIM- � � 9 ?
Email Address: joal s•e ma.rshem,,T h
I certify that I have authorized�Lf
Agent i Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: F-► J©
at my property located at bo(N E ol(Y, L 1 ,
in ') 1161) S1 L' 1 K County.
I furthermore certify that / 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 j
Print or Type Name
6 O . 1 C-, l-
Titfe
2 KI ZC,19
Date
/ 7This certification is valid through ` I �� I ���

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I
I hereby certify that I own property adjacent to J I o n ry. w I� sY I 's
(N a of Pr Brty Ow or) 1
property located at 0
(Address B c�k ad, etc )
on ,ins i,t� 4. 1� � �,�u
(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
l (individual proposin development must fill in description below or attach site drawing)
of [ o X l�
v
Y > j
v
(00 ' WAIVEFf SECTION '
I understand that a pier, dock, mooring pilings, 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 1ZL 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)
�I �Zz�
Signature S1 ngture �f!
�5 /�t• G���,�s LI U 7
Print or Type Name P 'nt or Type Namel
i'/ z6 �f c 7"C' 0 C kL
Mailing Address / Mailing Address
;I -Cc-'. ���,'�(� .�C Z- '
ci44tataOp Qt%Stat tp
r7oq-zo)-og79 7
Telephone Number T phone Number
i lzg�/s
Date _T Date
(Revised 611812012)

C kr
4J LkK-A-
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to P P, n I',D
(Name of P operty Owne
property located at L ON C— J oc h+ br, i i( I Jn i'1G \
on (Addres1.s, Loot, Block, Road, a c.) ,� /�y� ICk O c,. )
N.C.
(Waterbody) (City/Town and/or County)
The appli nt 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
t (individual proposin development must fill in description below or attach a site drawing)
p—I
I BcrtT LsFf
o-
` I
o a >f y' `
I
(ov WAIVEMSECTION
I understand that a pier, dock, mooring pilings, 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 formation) (Adjacent Property Owner Information)
�Y
Sigma Signature
Print or Type Name (� 1 Print or yv JUarne
lVZC, Cc�f ra�r(A',
Mailing "SS Mal g A Brass
/l7c�ts71 b NrC—
Clty/Statemlp City/St tee
Telephone Numb r 0 Telephone Number
Dare pate (- ycj t l
(Revised 611812012)

Fk-1 W kc w
.Shej
i / m rn A/R,<671�
V-^ e 5 . n'10, r51, � )Cj C,.q b`k v\ S , C �+c
72
ay �
WL

Date Received
Date DePosIted
Check From Name
Name o/ PW.0 Hoidar
Vendor
Check Number
aCheckmount
Permit NumbanCommanta
Receipt or Retun&7?wffocated
Column/
Column2
Column3
Column/
Co1umn5
ColumM
Column7
Column8
Column9
19
P motto M rin
Ma
F' P m tt
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