74612D - Smith

CAMA / DREDGE & FILL No. 74612 A B C Q
^� 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 �� j`� . i I oc)
�, ❑ Rules attached.
Applicant Name INN•�TY� Project Location: CountyC)A,11o„a l
Address kn `l�G�btr �fLCr�� Street Address/ State Road/ Lot #(s)_ 9 1O \
CitY�n� "'A State_�1C ZIP - ,S aL q
Phone # �89 '8 9 i � S(d)Q `�--' ' ' a 1
�) � E-Mail � �� Ste. ��A1� •subdivision
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Authorized Agent
City a .0
ZIP K S
Affected ❑ CW
Ew PTA AES PTS
Ay `L *Phone # ()
3`1 S River Basin
AEC 5 : ❑ OEA
19
HHF IH ElUBA ElN/A
Ad'. Wtr. Body
1 Y �'
n ^ c. (nat h4i�/unkn)
El PWS:
Closest Maj. Wtr. Body
��l )La-1 710 SS s %�^
ORW: yes /
PNA yes / no
Type of Project/ Activity
(Scale: E'l = ZG I
Pier (dock) length
Fixed Platform(s) _
Floating Platform(s)
Finger pier(s)
Groin length
number
lead Riprap length r5
avg distance offshore 2
max distance offshore 2
Basin, channel
cubic yards_
Boat ramp
Boathouse/ Boatlift
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Agent or p'cant Printed Name Permit Officer's Printed Name
Sign ture "Pl7�/
ea o pliance statement on back of permit �� Sign t
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Application Fee(s) Check # Issuing Date Expiration Date

Name of Property Owner Requesting Permit: 1 I
t'Y1 c
Mailing Address:�-
Phone Number:
Email Address:
►_nk. 1� � 1 � N �- a�1 �
L - 1 - fI�9 i
l ►115m�-,Sl�o p ho
t certify that I have authorized g -`-
%s t e l c Agent I Contactor
.gym
to act on my behalf, for the purpose of applying for and obtaining all LAMA permits
necessary for the following proposed development:
at my property located at
in 4County.
l furthermore certify that / am authorized to grant, and do in fact rant
on to
Division of Coastal Management staff, the Loca/ Permit Officer and weir ag its/ o ente
permit application. r
on the aforementioned lands in connection with evaluating informateon related to this
Property 0WrW Infomtation:
_ . ature
' o W 0�
Print br Type N me
QI� �r1t r
7Ve
This certification is valid through I i

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
r-^ , r
I hereby certify that I own property adjacent to _ ±� Pi i / 's
(Na of Property Owner)
property located at �/�� � 7�/j �t
X(Address,j�j� Lot, Block, Ro }
on e- , in ti , N.C.
(Waterbody) (City/Town an/or County)
The applicant has described to me, as shown below, the development proposed at the above
' I have no objection to this proposal.
have objections to this proposal.
vESCRIPTION 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. jIf you wish to waive the setback, you must initial the appropriate blank below.)
"f L
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Properly Owner Information) . (Adjacent Property Owipgr Infournation)
S
6-L2 -,-772"17' / e Xe)
M
Telephone Num r / email address
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 ��/?'� 4 .
s
property located at C/ 6)ff1 v f (Nam6 of Prdperty Owner)
a(Address,') Lot, Block, R d, �)
on t/ N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
1
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual prryposing deve%p~ must flit /it descrfpdon below or attach a she drawing)
WAIVER SEC, TION
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
ma wish to waive the setback, you must initial the appropriate blank below-)
ado wish to waive the 16 setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Inforrru
/on) (Adjacent ProPerty Owner Information)
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Si tore r
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Pnnt or TypeICA
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TB one Number/email address
Date
'Vakd for one calendar year after signature' (Revised Aug. 2014)

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Dste Received
Date De osited
Check From Name
Name o/ Pormit Holder
Vendor
Check Number
Check
amount
Permit NumbenLomments
Receipt or Refund/Reallocated
Coh mnl
Column3
Column3
Column/
Columm5
ColummB
Column7
Columns
Column9
7/3/2019
7/3/20191
Ennett Marine Const/Jerry Ennett
Tim Smith
Coastal Bank & Trust
2303
$ 400.00
GP #74612
JD rct. 8528