69331D - Martin

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�CAMA / DREDGE & FILL
iENERAL PERMIT 5 Previous permit# A B
New Modification ❑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 I SA NCAC V % 2[Xj
❑ Rules attached.
Name \AA-o0R -�2piinl& 1 r Project Location: County
i 1 ye;�X IJ� Street Address/ State Road/ Lot #(s)
y_AA Ja 0 Stated ZIP Z3% I
O E-Mail Subdivision
Bd Agent Me i C rlwb-81� C1 r\( SfMV , U5
❑ CW IXEW ❑ PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
(es f no ) PNA yes
Project/ Activity
:k) length
tform(s)
Iatform(s)
er(s)
igth
nber
I/ Riprap length
distance offshore
c distance offshore
annel
is yards
p
� t
�oatli z X
Ildozing
Length
City
ZIP
Phone # ( ) —� River Basin CJ5 12
Adj. Wtr. Body C 2 ((naA /n
Closest Maj. Wtr. Body
NEEMNIIT1 YS II mirmmmmmmm
• i IN ar I11'iT I■rfI
_ ��71►JII����■■■■WriWir��
:. . . .
(Scale: 1 " : 3
❑ See note on back regarding River Basin

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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: V& �2 ay Mav-t ✓ , , Jv '
Mailing Address: , It w ✓ I> t,j e
Phone Number:
Email Address:
I certify that I have authorized des.5.e-
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at ` 4 I_1Ve.VyyiJQ'
in ?)VUnSw i'-IG County.
I furthermore certify that l 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 OwnerMformation:
Signature
�em D/\_ P46A vAW_\I v
Print or lype Name
0V �

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to t2a� Ma✓-ti',rn. S
(Name of Pro Owner)
property located at 114 I1V4V D✓iJG t L- 2 CJ _ Z (3_Z G (� NETS Pla}313Z
on �(Address, Lot, Block, Road, etc.)
F✓ CA , in SOK'il�r2�✓k N.C.
(Waterbody) 1,:v.(,� (City/Town 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)
At,QE 1 L.S.F1 F�QM WEsTCtN siVv
To EEO aF DOCVc
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wai
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.
Owner Inf,6, nation)
Signature V^.. r—
Print or Ty e Name
I Lf IZ►'v� v A% U-e.
nt Pr,qperty Owner Information)
,Sl/Zl/ L . /
Print T pe N e

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
l hereby certify that I own property adjacent to _ QacA � s
'' II (Name of Property Owner�
property located at �'1 Zyo- ( � i-ye— L- 2 �j- 2 7 - 2 CF12 H6TS P1sfi3f 3Z
ot F�>� �I��N (Address, Lot, Block, Road, etc.)
on , in .SM� hp��-i'
N.C.
(Waterbody)
(City/Town 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)
To f-N 0 of
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bacH
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wai
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.
(Propert 6wner Inform ion) (Adja my Property Ow r Information)
Sl iJa ire
Pnnt or Typ Nam Print or rype Vine
I1�% lLryw Uri✓� 0 1 v�,t D 4Q