75898D - Bush

�'CAMA / ❑ DREDGE & FILL No. 75898 A B C D�
GENERAL PERMIT Previous permit#
®New --Modification JComplete 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 0 e 0 0
j}/�❑ lesattached.
Applicant Name pIlf g 41-W /� 5� Project Location: County �� �f
Address 71-165G�l,0 OWL E_ //
City IW1Iit'i')/W'(y/ t State ZIP)RO7
Phone # ( ) E-Mail
AN 40
Authorized Agent a
Affected ❑ Cw r Ew ;<PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ WA
❑ Pws:
ORW: yes /0 PNA / no
Type of Project/
Pier
Fixe,
Flom
Fingi
Groi
Bulk
Basii
Boat
Boat
Beac
Oth4
Shor
SAV
Mor
Phoi
Wail
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Street Address/ State Road/ Lot #(s)
Subdivision
City _ ZIP
Phone # ( River Basin
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A building permit may be required by:
( Note Local Planning jurisdiction) /f Notes/ Special Conditions �Y/_e 2H, MW,A
Agent or Applicant Printed Name
❑ See note on back regarding River Basin rules.
O
Signature* Please read compliance statement on back of permit Signer re
90S4J� Cl______ _. � S / o w ! ada d
Application Fee(s) Check # Issuing Date ExpWaon Date

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! hereby certify that t own property adjacent to t iAU,(i 01 1
(Name of Property Ownw)
property located at i �`�
f Adddresa, UYL Block, Road, OW.) ---
on J t� i 4= 5 , in { �C-N.C.
(Wady) (Cttgown aftaor County)
The applicant has described to me, as shown below, dv deveWpment proposed at tha above bcoon.
x i have no objection to this proposal.
i have objections to Chia proposal.
DEsEmpTi67N ANWOR DRAWING OF PROPOSED DEVELOPMENT
Ondviduat PMPOa'ng dtvs#op"d must ON In deacr#Won below or attach a sift dntwi4
wyx IBC m
t understand that a Bier, dock, mooring poings, breakwater, boathouse, lift, or groin mW be sat back a
minimum distance of f 5' front my area of riparian access unless waived by me. (if you wish to waive
the setbac(, you must Wflat the appropriate blank below.)
I do wish to weave the t 5` setback requirement,
i do not wish to waive the t 5' setback requitement
(Property OMr* ittfort rNaMnY (Adjacent Property Owner tnfor)
Signature � Sigwryr.e�
Print or Type Name Print or T Name .�
?aL jam_.
MS&V Adftss
" , •• 1 C4Wj1c f� f i
crryrsraftzt�`' ) 3_ cl *, a �� ;
rewhor� WNW Tedeptrone IV"7*er
(PovtW 0912012)

ADJACENT RIPARIAN PROPERTY OWNER STATE_. MEND
I hemby certify that f own property adjacent to _ s
r-r (Name of Proper Owner)
property located at ._t L't K '; tr b i
(Address, Lot, Btoc�k. Road, etc•)
or �` t``: �.��"" i tom_! in (.t- Tt��3�i�•r: �! N.0
(Waterbody) (Cityipown and/or County)
The appiicant has descrbed to me, as shown below. the development proposed at the above location
,. !have no objection to this proposal,
f have abiections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in descripfion Mow or attach a site drawing)
WAIVER SECTION
understazti 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
Me setback. you roust initial the appropriate blank below.1
i do Irish to waive the 15' setback requirement,
do not wish to waive the 15' setback requirement
(Property Qwner Information) (Adj#c4Tt Property Owner Information)
Via__
Pant or Type Arame Fnnt t,(r T,-e:Vame
ix
Maifir g Address malft►g Addram
CaryaStata,rF Csty.'Siate,'tp
Te►ephone Number Teieohom NLmbef