72732D - Potter

�'CANI.,A / ❑ DREDGE & FILL No. 72732 A B C C�J
GENERAL PERMIT Previous permit#
New ---Modification [-]Complete Reissue ❑Partial Reissue 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 I SA NCAC 076 PeFO
❑ Rules attached.
Applicant Nam/f�/�d!C e �r C: �t"i / i >°2 , Project Location: County Z
Address '//W 5 `% d1t.0 G✓S / , Street Address/ State Road/ Lot #(s)
City O P al State ZIP
Phone # ( � 6) -21'il)- 0qq _E-Mail Subdivision
Authorized Agent City. ZIP
Affected ❑ CW ❑ EW ❑ PTA ES ❑ PTS Phone # ( ) River Basin 4/I J%P ae
AEC s : ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Bod /q/ �✓!�" O _ I y Oaman /unkn)
Agent or or Applicant Printed Name
�
Si nature "Please read compliance statement on back of permit"
Application Fee(s) Check #
Permit Officer's Printed Name
Signat e
3 i
Issfiing Date Expi tion Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to // a , +- �� j�a7"%rr' 's
property located at
2�E (Name o— f Property Owner)
l� �' /�/tl�l/�Ec^! C �,
(Address, Lot, Block, Road, etp.)
on _Xt,i.lrt f1— rvA-<TZ� ,i�ST c (L;;�, %�s7`c- �'� 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)
S+JAfkt trld 1 Jd-%
-Tee 977-AL-1 y:
WAIVER 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 tback, 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.
(Pro,Rerty Owner Information)
T�1KS'�cs Ace,
Print Jr Type Name
`'e- ti—& ''<�
Mailing Address
ityyjSta /Zip
AI c 6
Telephone Number
Date
(Adjacent Property Owner Information)
1
Signature
Ovn fee vo j
Print or Type A19me
- q I i ti ndreW,
P
ling Addr ssrALt ak49
/Sta e/Zip
IlU 1;21K V r>llg4
Telephone Number
Date
JAN 2 8 2019 (Revised 611812012)
DCM WILMINGTON, NC

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 'z2t)aQ U s F1e'E -77e/C s
property located at
(Name of Property Owner)
�(; �' Jg Nc>l��fi�� J<�
(Address, Lot, Block, Road, etc.)
on N r' s ( `r' w , in HA rNp fTt 1' (7- , N.C.
(Waterbody) I I (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)
f/rlt2/'If
/ 1 /it,/ c</ �
WAIVER 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 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Cs: /mod
PCsTR✓iP�5 l
Ma " ing Address
C✓"3
C#/v T-1r76 b 99,
Telephone Number
Date
(Adjacent Property Owner Information)
i ature
Print or Type ame \\
Mailing Address
City/StatelZip
11 0--,2'7 o- 1
FiECEIVET&phone Number
1 - 29- /y
Date
JAN 2 8 2019
(Revised 611812012)
DCM WILMINGTON, NC

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: �i7v w (-Rs Arc P T -e-t
Mailing Address: LZ s
sr� d tic Z 5(yq3
Phone Number: 6' g-) 0 0 9 3 S
Email Address:
I certify that I have authorized 14ce
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: 1�� U� %�Sc,,c Cl ,✓�
at my property located at
in j2't)d�� County.
A,Ecj S /?<
G ?,-fW,3
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.
Property Owner Information:
Signature
Print or Type Name
��[.�i✓c`I c
Title
/ / , / / /V
Date
RECEIVED
This certification is valid through / / Zg / ?� JAN 2 8 2019
DCM WILMINGTON, NC

DaN Reca/wsl
Date Deposited Check Flom(Name)
Name o/ Parmlt Holder
Vendor
Check Number
Check
amount
Permit Numbe lComments
Receipt or Refund/Reallocated
Columnl
ColumnP Column3
Columnd
Columns
ColumnB
Column,
Column8
Column9
_
1 /30/2019 Ace Potter same First Citizens Bank 6292 200.00 GP #72732D DW rct. 5865D