74322D - Roberts

Q-CAMA / •.DREDGE & FILL NO. 74322 A B c
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 15A NCAC ,Zll - �/ 0(�
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Applicant Name;De,e P,k k o�,P!L
Address G . W nl dw'm d L "0/i Y01,
City P State ZIP?Phone # Zff
) •Q E-Mail
Authorized Agent
Affected ❑ Cw ❑ EW ❑ PTA 4ES OPTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / (no)
no PNA es no
❑ Rules attac e .
Project Location: County BEN I
Street Address/ State Road/ Lot #(s)
SAME
Subdivision
City
ZIP
Phone # ( ) River Basin Wo/e 00PA
Adj. Wtr. Body Cie, (nati /man /unkn)
Closest Maj. Wtr. Body 111kVA/
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Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit"`*
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Application Fee(s) Check #
Permit Officer's Printed Name
Signature
a42
Issui g Dat4 Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Derek Roberts
Mailing Address: 500 E Windward Landing PI
Phone Number:
Email Address:
Hampstead, NC 28443
910-431-0863
[e-mail]
I certify that I have authorized Chase Elum
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
Rebuild dock, boat lift and seawall.
at my property located at 500 E Windward Landing PI, Hampstead, NC 28443
in Pender
County.
l furthermore certify that 1 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
Derek Roberts
Print or Type Name
Owner
Title
3 I 1 1 2019
Date
1 RECEIVED
This certification is valid through / l I
02 2019
DCM WILMINGTON, NC

DJACENT RIPAR{AN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to I-c)S
Property located at V a (Name of Pro rty Owner) s
�r J(_
on (� -��,�5 ( (Address, Lot, QIock, Road, etc. )
in 1 lc,r J e�c.r�
(Waterbody) ) , N.C.
�) (CitY/Town and/or County}
The plicant fps described to me, as shown below, the development proposed at the above location.
J
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in desorption below or attach a site drawing)
0 UAh
WAIVER SECTION
I understand that a pier, dock, mooring
minimum distance of 15' from my area ofiriparian access runless wa ved, boathouse,ftbyrme + (If moutwish tbe back a
the setback, you must initial the appropriate blank below.) y to waive
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
i, , OR— ty Owner information}
Signature
Print or Type Name
Mailing Address
CifylState/Zip
Telephone Number
Date
or
Mailing Address
Citylstatel ip
Telephone Number
Date
Owner information)
(Revised 611812012)

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\ RECEIVED
DCM WILMINGTON, NC
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Dare Received
to De sited Check Fmm Name
Name of Permit Holder
Vendor
Check Number
Check
amount
Permit Numbe (Comments
R—i t or Refund/Realkxated
Columnt
Column2 Column3
C.1-4
Columns
Column6
Column7
Column8
Column9
6/512019
Ca,qlus ,ildin Coma
er k Roberts
P
1371
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GP #743
W r 8171