69270D - Lubbers

t. L"
CANNA / DREDGE & FILL b�
A B
"ENERAL PERMIT Previous Permit # `' r
+ew [--Modification❑Complete Reissue El Partial Reissue Date previous permit issued
>Yized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
Rules a hed.
it Name L'��S Project Location: County L-Un
Y ✓VU i Street Address/ State Road/ Lot #(s)
41
V State -ZIP ��'l,(J t- l �.t/V��, VIO
q$f6) 1 -7 g3g,;;�Mail
i:ed Agent pl"Y✓LC & f .*'✓L14
I ❑ CW kW )ITA ❑ ES �p PTS
❑ OEA 0 HHF /❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes PNA yes no
f Project/ Activity
)ck) length
latform(s)
Platform(s) X
Aer(s)
h
imbt
id/ Rip length
g distanc&offshore
ax distance shore
hannel
bic yards
Tip
Ke/ Boatlift
e Length if —
not sure yes
•ium: n/a yes
yes ;
Attached:
Subdivision
City b' LLI'!/ E-/(C ZIP —Z-A'
Phone # ")' River Basin
I'
Adj. Wtr. Body C" Tw AJ
Closest Maj. Wtr. Body TWS61L- 'So otir
(Scale: / fl
ng permit may be required by:
Local Planning jurisdiction)
❑ See note on back regarding River Basin r

%�aG� �v I �,U i H��i'�!7�,Ti�lr�; ������ r,.�,�; •�, ��� f{`;!` r��'��"�_IC!; i ����
Name of Property Owner Requesting Permit: r U
Mailing Address: —_-73 � r �n r 4u �� J-),r
�jc ? q LI
Phone Number: 7 �S
r
Email Address:
I certify that I have authorized
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all. CAMA permits
fc
necessary for the following proposed development:. e 1e45{ 30
CAJ U)( ock.
at my (property located at c
in 1 �V��� County.
B(Z� i4111�CLII 13eoc(r\ a
I furthermore certify that I am authorizes' 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.
Print or Type Name
C(-,) A e �-
Title

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 1'�LE�g, Llimas 's
n (Name of Property Owner)
property located at 112-IV CAJ20i-TEA 9LVI).
n (Address, Lot, Block, Road etc.)
on !jgN�i IANNEI- in �pwL LN , N.C.
(Waterbody) (City/Town 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 description below or attach a site drawing)
R.e✓'^UV�
wig to C4 f �oc,k .
a�z
WAIVER SECTION
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 by
me. (If you wish to waive the setback, you must initial the appropriate blank below.)
a I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Propefly Own I rmation)
`�—
S -gnature
5'1e, /-,�Ze arc -
(Adjacent Property Owner Information)
, .i
Si n ture
'To14 1 L, 1WCE1CS
Print or Type Name
Print or Tvpe Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �`, s
Name of Property Owner)
property located at { i 1���1h_ 1�C
on
(Waterbody)
The applicant has described
locat on
(Address, Lot,,Block, Road, etc.)
in A) sa f l h N.C.
(CityrTown and/or County)
to me, as shown below, the development proposed at the above
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAINING GF PROPOSED DEVELOPMENT
(Individual proposing development must till in description below or attach a site drawing;
r P4' `
tN ( 4o,rn t-'n c < c�(
l `
1 �
WA6R SECTION
I understand that a pier, dock, mooring pilings, moat 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.)
iU. I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' srrt',.;ack requirement.
(Proper Ow" ►4tformation)
,
S gnature �—
Print or Type Name
?'
AA.iNnn drieifRS.S
(Adjacent Praperty'10wn7r Information)
.4i cntfure
�drer��
Print or Type Name
Mailing Address.w-