69303D - Jordan

J /
1jCAMA / DREDGE & FILL +,,p 5P
A B
aENERAL PERMIT
Previous permit#
Mew `iModification ❑Complete Reissue El Partial Reissue Date previous permit issued
•ized by the State of North Carolina, Department of Environment and Natural Resources /
07
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
_ f
14
EJ Rul4s attach@d.
t N e �� A v ICV -
Project Location: County -,9 S, e
�x
Street Address/ State Road/ Lot #(s)
State C ZIP lc'
4-
1-� j
q1 0) 2 �f 5 - 313 E-Mail
Subdivision '
ad Agent —
City_ d ZIP
❑ CW k1VW PTA ❑ ES ❑ PTS
Phone# ( ) River Basin
ElOEA HF ❑ IH ❑ UBA ❑ N/A
L
Adj. Wtr. Body (nax'rr
❑ PWS:
yes /� PNA yes / noClosest
Maj. Wtr. Body
Project/ Activity
:k) len!r
� itform(s)
er(s)
igth
nber
sic yards
oatl' t1
Length
7
c
A
(Scale: Z
,ttached
ig permit may be required by:
_ocal Planning Jurisdiction)
❑ See note on back regarding River Basin

Cg -r1i�r��
Name of Property Owner Requesting Permit: D L ram- � � � �fC-� 4 rl
Mailing Address: r b lab k
Phone Number: I u - q j 313
Email Address: C-m (4 Z
1 certify that I have authorized n ,
Agent / 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 L%,09,7 Lf A :51
in k z✓ County.
I furthermore certify that l 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
Print or Type Name
dJ elm
Title

Melissa Dombalis
9197825547 p.2
From: 9103284804 Page: 2/2 Date: 91212017 11:48;06 AM
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby. certify that I own property adjacent to �- r� '� s
(Name of Property Owner)
property located at
(Address, Lot, Block, Road, etc.) _ N.C.
on '4 �'dc n �r ( _ , in S tic (' 4 •
(Watsrbody) (City/Toti m 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 objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in d "on below or attach a site drawing)
l% fc�
WAIVER SECTION
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.
(Property Owner Informstlonj (Adjacent P party Owner I formation)
Zi
1 r.,r l . i t• i� s1' _
Signature Srf (/ Ti
16•? / i r •^i ri't �JGG�/fS r, V /
Print or Type Name 7 L Print or Type Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ��� '� �� rU1( n s
(Name of Property Owner)
property located at -
on
(Waterbody)
The applicant has described
locat'o
(Address, Lot, Block Road etc.)
in 5U;I L� "I
(City/Tow and/or County)
N.C.
to me, as shown below, the development proposed at the above
I have no objection to this proposal.
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,
f , I r2't 2
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or grd
must be set back a minimum distance of 15' from my area of riparian access unless waived t
me. (If you wish to waive the setback, you must initial the appropriate blank below.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner I formation)
Si to
g�b �v o �` `✓
(Adjacent Property Owner Information)
_ lJh,,t,&4 -w
Sa^nature , I
irle.y # • EnrIIS
Print nr Tub NPMP.