68548D - Leo

CAKA / EADREDGE & FILL 99 - A B
4 'J .-1
ENERAL PERMIT I'D' 1- Previous permit #
<New —Modification El Complete Reissue --partial Reissue Date previous permit issued—
)rized by the State of North Carolina, Department of Environment and Natural Resources
'u)l 4 . , (
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
ules attached.
rit Name_I�A C, Aicx I AProject ❑
Location: County 10
State /VCZIP c/3
zed Agent
J 0 CW CIE )QJPTA ,Otg 0 PTS
EJOEA ' OHHF E11H El UBA El N/A
1:1 PWS:
yes � PNX no
-1
of Project/ Activity
D1%, length
'fo;
l atfo (s)
g Platfor
pier(s)
ength 7� ember
_;�)Uprap length
ig distance offshore ak iax distance offshore
:hannel
jbic yards
mp
use/ Boatlift 4e-
0
ie Length
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not sure yes
rium: n/a yes
yes
F
Attached: eqe>�_n. i.75F/—=0M OMME
ing permit may be required by:
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City �1 zip
Phone'# River Basin 4fA
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Closest Maj. Wtr. Body 0 7[
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N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date `( _._.
Dame of Property Omer Applying for Permit;
-Rcid-I'd k . Leo
Mailing Address:
I certify that I have authorized (agent)C" x Q p to act on my
behalf, far the purWse atapplying for and obtaining ail CAMA Permits aftessary to
install or construct (activity)
at (my property located at)
,
This certification is valid thrn (hate) --, rI) S`-,� (�

ADJACENT ittPj&H P, OEM 21M STATEMW
I hereby certify that I own property adjacent to � ���� �r , �} 's
(Name of P
property located at. IS 112-- �-
t 1 i1 1aar�selocK, KtiAtq e1
on �C,� �, ins
(waterbocty) ihrRown
The applicant has described to me, as shown below, the development prop"W at the above
location.
i have no objection to this proposat.
l have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
.. ::::a, proposifrg devetopmentngAt Mkt iE�C/ Qp I N or attach a sft d�awtnW
WS 9U' ad' /J�III'�1r��C �l C' � dOro/�et►�fY a ko y rtee,4
WaM SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distance of IS from my area of riparian access unless waived by
me. (ff yqu wish to way the setback, you must initial the a
ppropriMe blank below,)
i do wish to waive the 45' setback requirernent.
I do not wish to waive the 15` setback requirement
(Adjacent Property or Information)
-:Z-Z'A.4
-
Signatureo
Print or Type Name

ADJACENT RtPAMAN PROPERTY OWNER STATE�#�T
t hereby cerWy that t own property adjacent to 2�� s
sme of Progerty Ptmer) -
property toted at (A-4N},�,,}� j
& v"r Lot Block, r .l
on VlK tiA);A C- KEEL in N.C.
(Waterbcdyj atylTown and/or county)
The applicant has described to me, as shown below, the development proposed at the above
location.
0/- 1 have no objection to this proposal.
l have objections to this proposal,
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
kxgvi fuaf proposkV development muo ffH In d"adpdon holow is !`avach * sft drawing)
tree
WAIVER SECWN
1 understaod that a pier, duck, mooring pilings, boat ramp, breakwater, boathouse. lift, or groin
must be set back a minimum distance of IV from my area of riparian access unless waived by
rrp.Npf you wish to waive #t setback, you must initial the appropriate blank below.)
` I do wish to waive the 15' setback requirement.
I do not wish to waive the W setback requirement
(Adjacent Property meter lnformatton)

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