69401D - Leo

GIAMA / ❑ DREDGE & FILL , �� A B
iENERAL PERMIT
Previous permit #
New ❑Modification El Complete Reissue El Partial Reissue Date previous permit issued
ized 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 ' ules attached.
Name VI
f I Project Location: County j. Z4 l �^
34 ,-V Street Address/ State Road/ Lot #(s)
State &�ZIP b
61 ) LN E-Mail
ed Agent
El CW �A[] �ES❑PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ P1A`:
yes / (no ) PNj
Project/ Activity
ck) length
atform(s)
Platform(s)
U
iier(s)
�ngth
amber
id/ Riprap length
g distance offshore
ax distance offsho
hannel
jbic yards
mp
9
Bulldozing
i
ne Length
not sure yes n
Subdivision
City ZIP ��a'f
Phone # ( ) River Basin y •Ad
j. Wtr. Body 1 + '✓ �- nat
Closest Maj. Wtr. Body
kacaie: t ; Z
:)rium: n/a yes �...-_._ ��-.._.�—J---I I �—
r Attached: yes no .,,
El See note on back regarding River Basin
ding permit may be egLred by:

AGENT AUTHORIZATION FOR C
Name of Property Owner Applying for Permit:
Mailing address:
Phone Number:
I certify that I have authorized—�
Agent !Contractor
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of
at my property located at
in ��--- County.
This certification is valid through Date
(Pro Owner Information)
gnature
Print or Type Name
Title
Date

ADJACENT RIPARIAN PROPERTY. OWNER STATEMENT
adjacent to
t hereby certify that i own proQettY ad1 —11 , (Name of Property Owner)
I
property located at G 1
(Address, Lot, Bloc Road, et .) N.C.
on V i� �1' N , in
(Waterbody) (CitylTo andlor C unty)
The applicant has described to me, as shown below, the development proposed at the above
1 ti
I have no objection to this proposal.
_ I have objections to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(IndlvldLW prgxWng development must fill to description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or grain
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)
V I do wish to waive the 15' setback requirement.
I do not wish to waive the I setback requirement.
(property Owner Information) (Ad[ -cent Property Owner Information)
44 1'lG 4t
i aS
lure y f 5 fore*
$�� C-A
Pnnt or Type Name ��--,, �� Print or T Name
1� Atios�--taf� v2
e, gAddres y &— 1 '' gAd ross
Mal
Star zrCity/State2;p
city/2 j
C11 -Zl -Co 33ioL�D` l • r.
wl....1..,. ! email Addrass

ADJACENT RIPARIAN _PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to`EgL. ' �o 's
(Name of Property Owner)
property located at "I
!l (Address, Lot, lock, Ro d, etc
on _ �%C_.-- , in N.C.
"-) (Waterbody) (Ci (Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loca o .
I have no objection to this proposal.
have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Ind vrdual proposing development must fill in description below or attach a site drawing)
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.
operty Owner Information) (Adjacent Property Owner Information)
�J
Ig, 1\t%1i�1� t'r L�U s�wnd r� VJC�� t Vl
Prrn e:- I e w'i2 t �� rl% �� Print-h Type
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