72771D - Williams

2,UCAMA / KbRWGE & FILL NO. 7277I A B
GtNERAL PERMIT Previous permit# -,- "e 0
GW*ew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued ( ems
As auth/ori_zed 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 �x
!,� / files a ched.
Applicant Name VV 4mNS Project Location: County //�Jyn/ /l//7
Address lilStreet Address/ Staten Lot #
City / State fi( ZIP 2
Phone # a) -Mail
Authorized Agent (/► oL1 zcf
Affected ElCW EW PTA �S ElPTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ WA
❑ PWS:
ORW: yes no PNA yes e no
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Phone # ( -j---^ Riv Basin
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** Please read
statement on back of Dermit
Fee(s) Check #
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting
q g Permit: '1L%� ry
Mailing Address:
� S
Phone Number: -q/d - Iiiv/- SC 11
Email Address:
I certify that I have authorized=.v�y c �� /�i�i�f �✓G
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
A)0A) /, ]^,
at my property located at
in4/—L)J- County. '
l furthermore certify that l 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
`/'.4a j
Print or Type Name
e 6'VxmV -
Title
/ /A.
Date
This certification is valid through —/—/

CERTIFIEDMAIL - RL"URN RECEIPT REQUESTED
DIVISION Of COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONlWAIVER FORM
Name o� Proporty Owner ,j, [ L� i
Atldre.-.�.t of Property. -LIP 2unt
fLot Or Strut Ar_ sow of Road. C4V i C0ow)
A.genl'a Marne ./ i ( ' � t
I hereby ovffy 00 t own prorerty adja nt to ;he above reierenceC proWN Th i indnrxdueJ
spoing for this pumit hs►e ftseribed to -10 as shbwft on t-'.c attaches orawi g t1he clevv--�rtprnem
Bey an propm+ng A dwcrst1a0f1 or drawing ,vpih d!mrarrttillL%gust be crraw!W.Jh ra IefEerf
I have no nbteclions to this prope i I have ohjsovms to this propu�a�
N you hzv& *bj*4ftne w whet is 6e hWpireposed, you must natiify the Dfidsion of Coastal MWn enl
(DCM) in w yNigr wrNurt 10 doyo of mc**m of shrs norAw Cofamet kWermaeon for UCAI offices is
aysrleble►rtetlrQorbycalAng t-BBB-4RCDA rX.
No fWonaa is considrrod " somo os no objdclran n y ov haw been no~ by Car fled arfait.
WAIVER SECTION
t urdwstand that a per. dock. mooing oilirgs.. b 4t ramp, txe4w*st&t, bwrthurno, or alit must
be sat OaMck a mlerimum diaterce of 15_, Arom my area of riparian access uo%*S%- w&mw by me ill
yw wish to waive the setback, you must Irsitlai tyre apprcpdale btank below. i
lf1 tt � ��,r .,cG_ � d7 wish 1Gerfe3tve ttta t 5' setkai+dt rsqurerr►en;
I do not wish to wave the 15' setback rraqu+remenl
(Propw Y Omer Informstiionj
Si�a►rn+rr
F4* or I-Jre Name
+1�arartp A4�t>rsra
142
T*f*#* li Nurrrber I ERwwd Adaf"5
(RfRI PropsM Owner. Informabon)
5i��cilu .
C 1
�r yyC#/ ,
1i1 �itl' i 1
PMf Oar ype Name
OV Ad"As
1! c i P 6 L r1 rf
r�ZM
're190am 1Vumft,IF., WAdfross
40
(Rov,,%al aup 201ej

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to %� ��� �119�� 's
(pia a of Property Owner)
property located at a 7� �� t /v f C' f �/
on 1 (Address, Lot, Block, d, etc,)
N.C.
(Waterbody) (Clty/Town an /or County)
The applicant has described to me, as shown below, the development proposed at the above
loosen.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must till in description below or attach a site drawing)
WAIVER SECTION
1 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. (If you wish to waive the setback, you must initial the appropriate blank below.)
I d 1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Properly Owner information)
Signature V
�, W 10 s
Pgi►t or TAbe Name
Malting Addr�
mr-0), JV/ —
Telephone Number/email address
.S�oz—A
Date
Wald for one calendar year after sOaWW
(Adj Property Owner Information)
Si ruse' f
� � kev.
Print or Type Name
A"k,g A�dra}gs , / , A)C f ids
y�r P[[ �,S TVi
Te/ep "* Number/email address
Date*
(Revised Aug. 2014)

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Data Racahed
Daft Depo~
Cheek Flom ffLmj
Name of p~ HOMer
Vendor
Check Number
ch.�x
amount
FWm/t Num6enComments
Recta or RMund/NeN "tad
Columml
Co/umn2
Column3
Colummf
Columns
Columrb
Column?
Cohmms
Co1umn9
7
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