72389D - Svoboda

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-. J;'] CAMA / ❑ DREDGE & FILL No 723 89 A B C
GENERAL PERMIT Previous permit # G)
New --Modification El 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
❑ Rules attached.
Applicant Name 1 I I (JC1 21 LV S✓U I I i2AA Project Location: County k)el.J Q n o ,r
Address &011% 9. IQndr&-jS L4Y\X
City ' c-`r �nnon State V 11 ZIP 2 U2 6
Phone # (&O) 3.157.- Blq,E-Mail
Authorized Agent Ttr; P 2' y,
Affected ❑ Cw MEW )PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes j no PNA yes / io
Street Address/ State Road/ Lot #(s)
Z � �J.
Subdivision
City ('0YY\\V\'4Y'\ zip 181411
Phone # ( ) River Basin C Fp'
Adj. Wtr. Body ur S ("tu„rIt ( (na� /unkn)
Closest Maj. Wtr. Body 19--❑t-\i \_j
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Agent or Applicant Printed Name—�
Signature Please read compliance statement on back of permit"
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N ?,map - 41 &
Application Fee(s) Check #
Pev/ itofficer's Printed Name
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Signature
Issuing Date Expiration Date

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Name of Property Owner Applying for Permit:
Mailing Address:
cQutp sk. Q,
stSnrv�r�� �� `ZA22 (,Cp_
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I certify that I have authorized (agent) JC4t act an my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (acth=ity)
at (my property located at)
its
This certtficatto n is valid thrn (date) r'� l 1/ 44.
�0-
Property owner Signature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that t own property adjacent to
►-�vU CtJ s
(' r
property located a: 'rC me of Pronexty
(Address, lot, 81 k, ad, etc.) t
or �-� �. t('lt --- in �i C
(Waterbody) (CityfTown arib r County)
The applicant has described to me, as shown below. the development proposed at the above
�o tlon i
I have no objection to this proposal
I have obledions to this proposal
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(lneWdrral proposing development mast fill in description below or attach a site drawing)
RcPkee,� c,'s�!
iP�maJ
nth �",,R dock ell
'J
WAIVER SECTION
understand that a pier dock, moonng pilings. boat ramp breakwater, boathouse, lift, or groin
'nust be set back a minimum distance of t 5' from my area of npanan access unless waived by
me f It you wish to waive the setback, you must ttTittal the appropriate blank below
I do wish to waive the 15' setback requirement
Si do not wish to waive the 15' setback requirement
(Prom
(Property Owner Information) (Adjacent Property Owner Information)
"]1a;A1ei -Ib AYhLn&o—) y
ti'itnr�fhrritiis,r uttrrr"
�-r nt of T N re FP w# or Type N me
a;l g AMadinq Address
+t /Sfa xx City/StatelZr� Y 1
'e kfVrKr Ivurnber i ernaad address(140felepriorre lVtimGer ; emau atk:r> :k,
I
r , Revised Avo 20114
dabd fouam Calendar year after signature'

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• e �. L � � 1V #1�
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I understand that a pier, clock. mooring p&Vs, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distance of IS from my area of riparian access uniess waived by
me. Of you wish to waive tfto setback you rmat %tkW the appropriete blank below-)
1 do wish to waive the 15' setback requirement-
1 do not wish to waive the 15 setback requirement_
(Rev►sed Aug. 2014)
'Valid far one ca}endar year after signature'

MITI IF,

Del. R.C.WW
Date
Dspositod Cheek From Name
Name of Pennlf Holder
Vendor
Check Number
Check amount
Penult NumbeNComments
Recel r or Refun&Reellocafed
Columnl
Colu=2 Column3
COWIM4
Colume
Colume
Colurm7
Columns
ColumD
1/10/2019 Terri Pippin/Pippin Marine Construction Marianne Svobode i Wells Farao Bank 4965 200.00 GP #72389D SS rct. 7813D