72331D - Whaley

✓❑CAMA / 61REDGE & FILL �, 1J' '\� N0 72331 A
9 ,ENERAL 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 /no�
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC (/% (] �(
❑ Rules attached.
Applicant Name vZa�t)_k/ti/1 i �
Address Po. Fce 576
City4/Y' P�QCI�I State NC ZIP P,1
Phone # ( /0) 6 IIq Ile? E-Mail
Authorized Agent
Affected El Cw Ew PTA s Ts
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes /6 PNA 0 /no
Project Location: County, ✓'�Wrll y
Street Address/ State Road/ Lot #(s)
Ile' S. 11)lP f � �A-j
C (9
Subdivision 1110 N"04 Hd r40l-
City k IV✓�1'i ZIP 09
Phone # ( ) River Basin
Adj. Wtr. BodyUld i nat unkn
Closest Maj. Wtr. Body `���� 5UL't4d
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Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit **
A60E-a- A 274 %
Application Fee(s) Check #
Pe1t0 icer's rint Name
Signature
Issuing Da a Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
/ Contractor,
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: l k-= sr�� 11 0, / ;�- rn/c
cl- aI r0� y- C"
at my property located at
in O ,-) N&,-,j c -,e/-County.
I 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 evaluafing information related to this
permit application.
Property Owner Information:
0 LJ N t I
Title
3 1_ki 1 5
Date
This certification is valid through / 1 " I
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hereby certify that I own property adjacent to 's
(Nk3Me of Property Ow er)
property located at D v c-
(Addr ss, Lot, Blo k, Road, a c.)
on , in G , N.C.
(Waterbody) (City/T n 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)
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)
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Print or Ty� Na e 9
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Mailin A ress
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City/s at I '
M /,/L)7
Telephone Number
Date
(Adjacent Property Owner Information)
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Print rr pe N e U
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Mailing Addr . s
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City/ ate2ip
Telephone Number
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Date
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(Revised 611812012)

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ENT
I hereby certify that I own property adjacent to X i'WOL E 's
( f P operty Own )
property located at �6t ✓( i
(Address, Lot, Ejlopk, oad, etc.)
on , in lL i t1kI -A N.C.
(Waterbody) (CitylTown andlor County)
The applicant has described to me, as shown below, the development proposed at the above location.
1 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
t��AR 2 6 2019
� o.a •'vS
WAIVER SECTIONi
I understand that a ier, dock mooringpilings, breakwater, boathouse it ft ordoin must be set back a
minimum distance of 15' from my area of riparian access unless waived b me. (If you wish to waive
the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
ZI do not wish to waive the 15' setback requirement.
(Prop rty Owner rormatio
Sign ature
/' Z
Prin Ty a Name ,
3 - Z- 2012
Date
(Adjacent Prope Owner Information) z
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Signatur � 0
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Print or T peJYame U �
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City/ t�elL' n
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Telephone Number
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(Revised 611812012)

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RECEIVED
MAR 2 6 2019
DCM WILMINGTON Nf_

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Dab DVOSItod
Cheri Fom Nu
Name o/P~ Holdr
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Check Number
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