69416D - Klitsch

CAMA / DREDGE & FILL 'rI
33tNERAL PERMIT d Previous permit#
:;New Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
irized by the State of North Carolina, Department of Environment and Natural Resources //`
�—� oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC-4 . M TI 100
—�- --�❑ Rules attached.
J it Name p �K� 1: 4 sc � ,, t Project Location: County ,";
XJ 23rA s+-
%� TSG& State ZIP
` ag )3Q- 0 E-Mail
:ed Agent 411; P d f a cyx 6,4.s$
❑ CW ❑ EW ❑ PTA IdES *1PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes /(no) PNA yes
Street Address/ State Road/ Lot #(s)
`S a y
Subdivision
City-- - ZIP
Phone # ( ) River Basin��
Adj. Wtr. Body V; S caivia (nat
Closest Maj. Wtr. Body �4_Tc J LJ
F Project/ Activity
.• .t i
(Scale: z
ck) length
atform(s) ONE 7--
Platform(s)
ier(s)
ngth
d/ ipra,,pol4ngth �±
distance offshore
uc distance offshore
cannel
)ic yards
np
se/ Boatlift
S+b^t
aG : 325S14
Length sue__
not sure yes
ium: n/a yes no
yes gn\[[ached: yes
ig permit may be required by:
_ocal Planning lurisdictionl )
Dwr' u k [l See note on back regarding River Basin ri

A EN'T Atli NORIZA LION 'FOFt LAMA PEROT APPi.1
A
dame of Property Owner Requesting Permit:
Mailing Address: , IZ
Phone Number;
Email Address. !
I certify that I have authorized 'll,aet
Agent / contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
�i /°
at my property located at t L ` 5.
in County.
County.
I furthermore certify that I 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

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
r� `�tVame of� rppe �wntr) L
property located at
�, (Address, Lot, Block, Road, efc !i�'
on �L ir, f`lC_ '<r� , N.C.
Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locati
Y' 1 have no objection to this proposal.
n
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 dr wing)
��► �,�� °l' SSAw � IPR h) he c, U,' �-
-'w r
betif" 5W
I
WAIVER SECTION
I 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 I forms 'on)
Signat r .
Print or Type Name
10 _5w
(Adjacent Property Owner Information)
SignquV * ?
-0*-e,•K dt a�ww/d S
Print or T pe Name
`fG�a/ F A 4- zla 6, a>l %Zr-

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ✓�/+�A/` ��f�`��7`�.� �i'�/e, �'s
Property located at / �� (Name of Property Owner)
on (Address; Lot, Block, Road, etc.)
in CrC. " ' N.C.
(Waterbody) (C41Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above locatio
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)
5w
t1�,leb
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set ba
minimum distance of 15' from my area of riparian access unless waived by me. (if you wish to N
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.
(Props ner Infor/ma�tion)
Suture
7�i�S�/�
P
Int
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Print nr Tvno Alamc �?Z �
Print nr TvnQ A/amo

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