69007D - Buckley

ZAMA / -- DREDGE & FILL
P�ENERAL PERMIT Previous permit# A B C
New -.Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
(�� ❑ I hed
Applicant Name') 0 � Vt li!-l( V Lkq/
Address C'� 7- i/t A �(,�{ I i A, vDV
City� V , Vk �► ^V) State_ zip
Phone # (W) I �D E-Mail
Authorized Agent U V h V, lG ( V 1 n
Affected
❑ Cw XEW
\1 PTA ❑ ES ❑ PTS
AEC(s):
❑ OEA ❑ HHF
❑ IH ❑ UBA ❑ N/A
PWS:
ORW:
^❑
*/ noPNA
gelno
Type of Project/ Activity
1 r
g j rL Aku �
�
Pier (dock) length
Fixed Platform(s)
20 XL ,T
Floating Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/
avg distance
Riprap length
offsho
i
-
max
Basin, channel
distance offshore
cubic
Boat ramp
yards
Boathouse/
Bo tlift
Beach Bull
zing _:��
—
—
—
---
—
Other
Shoreline
Length 2
SAV:
not sure yes 6o
Moratorium:
n/a yes n
Photos:
yes o
H,
Waiver Attached:
ves a.4
A, u es attac
Project Location: County )yt �y i "(iV Pr
Street Address/ State Road/ Lot #(s)
ce. AuLt ) u bi .
Subdivision
City VIM 110JJY 1 ZI P� r
Phone # ( ) River Basin
Adj. Wtr. Body Paz? S Creek (jai//man /unkn)
Closest Maj. Wtr. Body- IVW
A building permit may be required by: NC. HVt.+' tyy -eY
( Note Local Planning Jurisdictio
Notes/ Special Conditions
Agent c t Print Dame ;f-)
Signatu Please read comp ydnce statement on back of permit"
Application Fee(s) Check #
(Scale:
❑ See note on back regarding River Basin rules. k

ih
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
AGENT AUTHORIZATION FORM
Date:MW���YD.17
Name of Property Owner Applying for Permit:
Owner's Mailing Address:
/tor: a AveN� e
7-gy
Phone Number (W(J) 3 1" _F 7 S 0
Dee Freeman
Secretary
Namr of Authorized Agent for this project:
Agent's Mailing Address:
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity): `
(my property located) at
This certification is valid thru (date) 3� 8
i - 3 7 'y
Property Owner Signa ure Date
127 Cardinal Drive Ext., Wilmington, NC 28405
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
An Equal opportunity \ Affinnalive Action Employer
NorthCarolina
Naturally

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to _
property located at b;u
FA(Address, t � �� K- (Address,
(Waterbody)
(t 'a of_ll�rop w -r
Bloc ,Road c.
(City/Town and/or County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above location.
L � A 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)
—Z
Signature
Print or Type Name
Mailing Address
Cit /Stat
rtoip 3i- 7s`v
elephone umber
'1d%0l-7
Date
(Adjacent Property Owner Information)
n_
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Lip -JNK BVC r JiGA ass\
property located at� ;�"�i� e of !.,
rope e
MM� p (Addressc etc, /
on PPC1 ���K , ins�gAB�o • rNl N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above location.
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 bellow.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
,Q-, (n+4,
Print or Type Name
k;-d"SaHda:Nle��d
Mailing ddress
CNS((3
tatelZip
ti
lephone Number
s l C. 1901 7
Date
(Adjacent Property Owner Information)
Sign re
Print or Type N me
C /,�
Ma' ing Address
City/State2ip
Telephone Number
Date
(Revised 611812012)

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