69311D - Kahler

P P '!� 11
CAMA / 1 DREDGE & FILL p'J�' � 1-1 A B
6XENERAL PERMIT , Previous permit#
New Modification []Complete Reissue El Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources 1
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC (, l Rules attached.
Name A —'A Project Location: County
-42—A&- State
�N-3AA�++'1"Iail
ed Agent��
❑ CN/ ,*W >(PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes no PNA yes
f Project/ Activity 1 N STNL (- R(C"r-
ck) length J
atform(s) j �f
Platform(s)
)ier(s) V Wf Q
angth
WIN
d 'rap length_
�g dista offshore
ax distance fshor
:hannel
ibic yards `
mp
use oatlift
ne Length '-
not sure yes 0
69
xium: n/a yes n
yes o
r Attached: no
v
ding permit may be regkre
Street Address/ State Road/ Lot #(s)
J�A w 1 N 0 TrJ'K 4---
Subdivision
Gty "<�O a- G-tT ZIP
Phone # O n River Basin
Adj. Wtr. Body
Closest Mal. Wtr. Body
V' V
❑ See pote on back regarding River Basin

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Jact�tl
Mailing Address: �� --> � / ' / �i-e /I r7 G'` /Y -
Phone Number: �� 1
Email Address: L C/Yl �(/� ��' /' C
I certify that I have authorized j
Agent 1 Contractor
to act on my behalf. for the purpose of applying for and obtaining all CAMA permits
/ Q�
necessary for the following proposed development:
T �� Ti �')
at m7,r
o ert' located at a , ct � n/t UY
P Y Z
in 17 %�E� County.
l 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:
Signat re
z4Gt Y(1t �, '�Cl• {� r'� t�
Print or Type Name
�0t a����
Title
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Own
property / Name of PTOPOriy
property located at 4x JQ
On _L� W
, / / _ �/ ^ Address, Lot, Block, Rio' a )- N.C.
' /j li7jVl , _. ,n �'� and/or County)
(Waterbody) (City/Town
The applicapt 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.
.��I T
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groir
must be set back a minimum distance of 15' from my area of riparian access unless waived b)
me. (If you wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
4--�I do not wish to waive the 15' setback requirement.
(Property Owner Inform ion) (Adjacent Property Owner Information)
aignal S
ZL t
Print or Type Name Prif or Type Na
/�'G"c YQ
Madin ddress Mailin d ress
��. . - ,.4 /i / �� .i_ _. 11

.s
I hereby certify that I own property adjacent to rvtj "' erty Owner)
Name of rop
dy located at (VI'r'G N?`Y'�✓ -- —
prole p d,�andlor
(Address, Lo floc N C
on f, f I (,11.71 inCity unty)
( rfo
(Waterbody) bove
Tile applicant has described to me. as shown below the development proposed at the a
location ri
�( t y I have no objection to this proposal
I have objections to this proposal
DESCRIPTION AND/ DRAWING OF PROPOSED DEVELOPMENT
'rndividuar propost.,p ,i,isrCrit i»ust rill in description below or attach a site drawing)
f
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.)
1 do wish to waive the 15' setback requirement
_ I do not wish to waive the 15' setback requirement.
(Property Owner Information (Adjacent Property Owner Information)
1r)r\(V"
nature
rRntaru t� ��e
Print or > y e Name Print or Type Name
Mailing Address
Ma�Addre
City/State/Zip C> u i t f'