Thomas, Rick

[KCAMA / ❑ DREDGE & FILL N. O
78936 A B i:. c� D
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
p Rules attached.
Applicant Name _r j', p n Project Location: County
Address T % t - f Street Address/ State Road/ Lot #(s)
City � F State/° ZIP
Phone # E-Mail Subdivision
Authorized Agent City i ZIP
dCW ❑EW El PTA El ES ❑PTS Phone# O _ River Basin �!
Affected ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
-i
AEC(s): 1-1 PWS: Adj. Wtr. Body (nat /man /unkn)
ORW: yes / no PNA yes / no Closest Maj. Wtr. Body —
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Agent or Applicant Printed Name
Sig ture **ease read compliance statement on back of permit'"*
Application Fee(s) Check #
PermitOfflcer's Printed Name
Signat re
Issuing Date Expiration Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to l,O A, s
—I (Name of Property Owner)
property located at
Road,
on in N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
- -A_ I have no objection to this proposal.
I have obfectiong to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual prop sing development must fill in description below or attach a site drawing)
Po
dret 1
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater
back a minimum distance of 15' from my area of riparian
wish to waive the setback, you must Initial the appropriate
, boathouse, lift, or groin must be set
access unless waived by me. (if you
blank below.)
L Q, I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
(Adjacent Propert Owner Information)
Si na ure
Slj-f—;1pl ur1e
1J
Print or Type Name
P t or Type Name
,r
l
� l 1
Mailin Address
Address
aili Ad ress
l
City/State/Zip
City t e
61
i
3 Fri- GIC
Telephone Number
3/rr/
Telep one N mber
Dare
Dare
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to R r a tG rn ryr ,s
(Name of Property Owner)
property located at
(Address, Lot, Block, Road, etc.)
on TTv.we sz- d in gk N.C.
(Waterbody) City/Town 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 ogjections1to this proposal.
DESCRIPTION -AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
o �
i
frCp"��
i
4 n..
WAIVER 'E ION
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
ish o 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
(Props Ow�neerr Infoormation)
Sigz ure
iA
Print or Type Name
9 i fe Tern- 6ah-o
Mailing Add
(lam
City/State/Zip
l - ao(g
Telephone Number
.3h/
Date
[ling ddress
�yA tc� gsrlh r e
�1l�lte/7�,a I �S 2
Date
(Revised 611812012)