67905D - Dubose

_' CAMA / DREDGE & FILL
.ENERAL PERMIT
"New Modification ]Complete Reissue
El, Partial Reissue
i 905 A B
Previous permit #
Date previous permit issued_
rized by the State of North Carolina, Department of Environment and Natural Resources ' n
2oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC ��
. t {� r ❑ Rules attached.
it Name V Q �-� 9y b o 4t Project Location: County N� tv f4 a n oyio {�
To 0i..0 (a.o Dr Street Address/ State Road/ Lot #(s) -7jj Ca
oah Is-,State_L ZIP 2� 01 1 V f
t t11�) 2 S tj� E-Mail Subdivision 1 )_ II"� u
:ed Agent 111 1l U �► (�1 A City W Ie� �1 SL1 �7(� Ct�f ZIP 2 1
❑ CW A ❑ ES ❑ PTS Ph;one # (') River Basin
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body (nat
❑ PWS:
yes /� PNA yes /6
Closest Maj. Wtr. Body
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ng permit may be required by: Q W 1 {,
1 i,VIQV� Y (.a14 tt jI) ❑ See note on back regarding River Basin r
Local Planning lurisdiction)

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: J (e V a 0SL
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
70 AfZIC14'y .UXl VL-7
Xll�l6-N71: d/. G-,
,910-,,256-3297
/ Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in UQNOJ�I- County.
/ furthermore certify that / am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature
� e FE IJ�13osE
Print or Type Name
Title

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to , Je f'f &6051f 's
(Name of Property Owner)
property located at F7r7 //�/I/ 0-X1
(Address, Lot, Block, Road, etc.)
on 7U in LySE'16AisL11L&F XCh,�e Al. l_6 , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above locati
X_ I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in description below or attach a site drawing
Ri PLA66- �x,f�,,'1-o,1T41 G n o�
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set b�
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to v
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) (Adjac t r per
Si e Signa e
J eff Z) sue i �r�
Print or Type Name Print or Type3/►Je
Information)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �F' Dui6c 's
(Name of Property Owner)
property located at 7b PC t 1 CA d ' r:'
(Address, Lot, Block, Road, etc.)
on irk fFz1c6, 1 1)y4 i v? in a/R I (-N rS it 6,1(4, A), G, N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above locati
Z— 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 b�
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to v
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)
Si a r
P
Print or Type Name
(Adjacent Property/Owner Information)
z
Signature
F SjY�t�S �7�/✓
Print or Type Name
,r a,c/ J N/ _ a /c< i�%�