Parnam, David

JICAIVIA MDREDGE & FILL
r. NO. 78976 A B C D
GENERAL PERMIT Previous permit#
TtNew El Modification El Complete Reissue D 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
E'Rules att ched.
Applicant Name Project Location: County
ggE
Address
L Street Address/ State Road/ Lot #(s)
City i �`-Siate zlp''
Phone #
E-Mail Subdivision
Authorized Agent City ZIP
El Cw EW ,L).PTA El F-1 ES ❑ PTS Phone #
Affected River Basin
El OEA 0 HHF El 1H El UBA El N/A
\�
AEC(s): Adj. Wtr. Body (nat ffima /unkn)
El PWS:
ORW: yes rno// PNA yes noClosest Maj. Wtr. Body,
Type of Project/ Activity 'z
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)_
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
Shoreline Length
SAV: not sure yes ,,:,'no
..........................
fl
.........
Moratorium: n/a yes no
Photos: yes,; no
Waiver Attached: ves'+ no
A building permit may be required by:
Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent of Appl.i6nt Printed Name If
Signature Please read compliance statement on back of permit
Application Fee(s) Check #
(Scale:
E:1 See note on back regarding River Basin rules.
V
Permit Officer's PrintedName,/
Signature
Issuing Date Expiration Date

ADJACENT RIPARIAN PROPERTY OW. NER STATEMENT
'_
�".i� 0
I hereby certify that 1 awn property ad) acent to -(Narnp of Pro arty Owner)
property lo
cated at ! v®� Dp, vice. W's Al
(Ad ess, L !,.Blick , Road etc.) ,.
on �� ���� ff
rf .�l�cs N-G-
(Waterbody) (City/Town an for County)
The applicant has described to me, as shown below, the development proposed at the above
Ioc tiorl,. .
I have no objection to this proposal.
f hav_e_o_b_jectons to
DESCRIPTION �AN DIOR DRAWING OF PROPOSED DEVELOPMENT
Individual proposing pieveloprnent must fill in description below or attach a site drawing)
I'
4,
q /01`..
A
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dA
�y<
l WAIVER SECTION -----_.- - �
at a pier,.dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
I understand th p , .
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.) �--
A401'0' 1 do wish to waive the 15' setback requirement.
�Kf-.
(Pro
I do not wish to waive the 15' setback requirement_
on)
:2ature
Print or ype Name
Mailing Address J
�,
#d1itVISta AtelZip
!Telepho. umber
-040
Date
(Ad cent Pr ertygwner Information)
ype same
Nlai ' ddres
city/ tat ip
Telephone Number
Date
(Revised 6118121012)
Ile,

A0
rIY
A ACEi+il" RIPARIAN PROPERTY 01�11/�� 5P/�TAT ENT
1 hereby certify that l own property adjacent to % (Name df Property )
property locate
d at 3®/�! 0/ 1 Owner
(A Tess, i.ot, �i ck, Road, etc.} } N_C.
on .A /� I , in P'rV � J
(waterbody}
(City/Town and/or County)
- .
to--,Melshown below, the development proposed at the above
The applicant has described
location.
' l have no objection to this proposal.
l haves_b_j�cti_o_n_s_tohts_p�oposaL_
DESCRIPTION -AND/OR DRAWING OF PROPOSED DEVEIrOPMENs to drawin9j
(Individual proposing OeveloPment mkt nit �� description below or attach a
1
Cat G� �� 7L
yy �{ Ito La 0
WAIVERor I
�ECTI.O�I _ -__ ___ . - _
-�--`- mooring pilings, breakwater, boathouse, lift, or groin must be set
I understand that a pier, dock, g P
' distance of 15` from my area of riparian access unless waived by me. (If you
back a minimum appropriate blank below.)
to waive the setback, you must initial the appro p
I do wish to waive the 15` setback requirement.
1 do not wish -to waive the
.tIon}
Signatwf-e
do �d
Print or Type Name
,,% �►
Mailing AdOress
Telepl� ne,. umber
Dat
15' setback requirement.
(Adjacen operty Omer Information)
X
io iure
print or Type Name
Mailing Address
City/State/Zip
Telephone Number
Date
(,Revised 6118/g412)