76226D - Brown

CAMA [- IDREDGE & FILL NO. 76226 A B C
GENERAL PERMIT Previous permit#
SdNew 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 l� �% 1 * 1100
❑ Rule attached
Applicant Name_lffA
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Address-4 by
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City
State NL zip"
Phone # (�(Q)
Z�-E-Mail
Authorized Agent
Affected ❑ Cw
lCipW IJPTA KES PTS
AEC(s): ❑ OEA
❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
ORW: yes / n
PNA es no
Project Location: County_—f/Ll
Street Address/ State Road/ Lot #(s)
koy ?'N, i �� 41r. �` • i2o
Subdivision
Phone # ( -J—� River Basin V' '
Adj. Wtr. Body ; C!nan unkn
Closest Maj. Wtr. Body A-1-1-Q
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Printed
*r Please read compliance statement o#ack of permit
Fee(s) I Check #
Pe i nted Nam
Signatur
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Issuing Date Expiration Date

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CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property: -4t"'z�,-7C fz �t - �
(Lot or Street #, Street or Road, City &
Agent's Name #:
Agent's phone #:
Mailing Address:
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
I have no objections to this proposal. _ _ I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no objection if you have been notified by Certified Mail.
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.)
1AIE,_ I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number
Date
(Adjacent Property Owner Information)
Signature
CSC tC � U� S 5�'�e�t I-�6 s FLAP
Print or Type Name
J- 4J
Mailing Addre
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City tate/Zip
Telephone Number
S -11 aoac)
Date
Revised 611812012

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
(Name of Property Owner)
property located ata�� el%
��L (Address, Lot, Block, Road, etc.)
on _ IC e-��'r in v N.C.
(Waterlaody) (CiWtown and/ r ounty)
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)
O 'Q
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 I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
Print or Type Name
Mailing Address
City/State2ip
Telephone Number
Dale
(Adjacent
%Property Owner Information)
Signature
&-6c 4461) 1-4946/FAI!F2
Print or Type Name
Mailing Address
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City/State/Zip
- 7;7a�
elephone Number
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Da
(Revised 611812012)

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: a'17e
Mailing Address: ��6_ / �_
Phone Number: 7? :�?d 1
Email Address: w
I certify that I have authorized6-
-
Agent / Contractor elf
to act on my behalf, for the purpose of applying for and obtaining all
CAMA permits
necessary for the following proposed development: �Z-/j
at my property located at Z , l lq �j 1:11) A
in f(-/ A491 ounty.
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 evaluating information related to this
permit application.
Property Owner Information:
gnature
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Print or TTpe Name
Title
Date
This certification is valid through I l

Data R—f-d
Oat@ Deposited Chock From(Nema)
Name d PVmh Moaer
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Check Numher
Check
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I Permit NumneNCommont
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Column!
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