Scudder, Sam

®�ICAMA / L DREDGE &FILL NO. 75993
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GENERAL 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
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
O Rules attached.
Applicant Name "/ Project Location: County.
Address 1/'/
State ZIP = .
Phone # (')__ _ E-Mail
Authorized Agent
Affected CW
AEC(s): DOEA
❑ PWS
ORW: yes / no
,DEW GPTA DES DPTS
❑HHF OIH ❑USA ❑N/A
PNA yes / -no
Street Address/ State Road/ Lot #(s)
Subdivision
City
Phone # O
Adj. Wtr. Body
Closest Maj. Wtr. Body
ZIP
RiverBasin
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Agent or Applicant Printed Name �—
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si n �ture "Please read compliance statement on back of Permit"
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Application Fee(s) Check #
PermltOff cer s
Print -Name/
Signature
Issuing Date Expiration Date

I hereby certify that I own property adjacent to
property located at IN A ✓
on
(Waterbody)
(Address,
, in
(Name of Property Owner)
(City/Town and/or County)
I
N.C.
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)
IftwtoJL a C(eckivdtexlr
/ «Kd Staw4U
o� a
44+is Po✓ 4totn o�
seaw16ll1' i? kVtry�
WAIVER SECTION +'O IMoyck (tutaUS. �rt pAoejS(aluAj)
I 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.)
uate
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Property gwner Information)
Print or Type tllame
M,WAddress
S NC 2&SIZ
City/state1z.
�qW zS �/�NcAVAMAQVIC.fv-COVA
Telephone Nymbqtl email address
Dnfe
*Valid for one calendar year after signature*
(Revised Aug. 2014)

I hereby certify that I own property adjacent to ` >o kA- Jco CCrC✓ s
(Name of Property Owner)
property located at IN +4✓b6Yyi�Q�b✓;JC .
(Address, LoLBlock Road, etc.)
on CaAa ` , in PoAe Vvtoj I N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatio�l,'\ 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)
Cale` t�tWbVC. a 14 4fe -bu dt��✓
�� 1e�lact Seawo.11
O�CDo L vatLv. S� 2� l�c�c
G � 1
.5 QG W4l� wT�k VIYAY( I
qr«+ lj
WAIVER SECTION }0 t"^"�k �'�,60%. ap%& A
y P
I 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 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(PrppArty Owner I+ fo mation)
sigS��
eY
Print or TyI� e Name 1
I �� / l ary%4-rho- 2
Ma "WKS QV C Zc& SY Z
City/State/Zip 'Q
ZS'Z 249 a7y'1 Sw@ScJ ems, w
Telephone umbyr /email address
-4 / Z Cd
rll.Tra
(Adjacent Property Owner Information)
luI
signat Ye*
Eve ryvt 6 KI611
Prnt or �ype Nam
Ito vtaorVi�4{ �1JC.
Mail k.SddresNc- 2 I Z
City/StatelZip
Telephone Numb / email address
Date* �I
*Valid for one calendar year after signature*
(Revised Aug. 2014)