69191D - Massingale

�ICAMA / ❑ DREDGE & FILL
EN ERAL PERMIT .a Previous permit # A B
ew ❑Modification ❑Complete Reissue CPartial Reissue Date previous permit issued
orized 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�QQ
�J ❑ Rules attayhed.
nt Name To MaS5 I h � Project Location: County
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A`T5x-FYAw'FA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date March 25, 2017
Name of Property Owner Applying for Permit:
Tom Massingale
Mailing Address:
PO Boxd 2107
Shallotte, NC 28459
I certify that I have authorized (agent) Joel Klass
to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) replace dock
at (my property located at) 109 Fayetteville St. Holden Beach, NC
This certification is valid thru (date) �—�
'5 ) �"q) �

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Tom Massingale s
(Name of Property Owner)
property located at 109 Fayetteville St.
on
(Waterbody)
(Address, Lot, Block, Road, etc.)
In Holden Beach
(City/Town and/or County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above
loc
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)
Wr&CQ ZZW7-,
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.
(Property Owner Information)
Signature
Tom Massingale
Print or Type Name
PO Box 2107
dja0pt Prope,4 Owner Information)
Jordan
Print or Type Name
107 Fayetteville St.

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Tom Massingale s
(Name of Property Owner)
property located at 109 Fayetteville St.
(Address, Lot, Block, Road, etc.)
on , in Holden Beach N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
!!P�
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)
1�fGi C, lD c� J l %� /qOGjL
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.
(Property Owner Information) (Adjacent Property Owner Information)
*a4
Signature Signature * + c
Tom Massingale Karen Allred Dodd
Print or Type Name Print or Type Name
PO Box 2107 6521 Hollow River Rd.