69279D - Prevatte

]LAMA / DREDGE & FILL
�ENERAL PERMIT Previous permit # A B
ew _:Modification []Complete Reissue ❑Partial Reissue Date previous permit issued
-ized by the State of North Carolina, Department of Environment and Natural Resources ,j
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC � "t t I , 1 Zoo
❑ Rules attached.
t Name I v l I L,Y[ I'' { V�(,� i� Project Location: County NW (, P HA I'l oyp
1( f,jT 1 Cre C u u Street Address/ State Road/ Lot #(s) 10
lI VL State) VG ZIP �U (r eek wtk-
(ql-cu) 0 he nZ E-Mail M! r &ePABe 4." Subdivision
ed Agent w i Im 1 xi tvwWivre- L ll City [V (1wo'Lotal ZIPS
❑CW )^ )iPTA
❑ OEA ❑ HHF ❑ IH
❑ PWS:
yes no ,DNA Nei / no
Project/
� � l
❑ ES ❑ PTShone # (TO River Basin
❑ UBA ❑ N/A Adj. Wtr. Body pace cre Ia fh*a)/r
Closest Maj. Wtr. Body, w
rIN
(Scale:
:k)length
i
itform(s)
Platform(s)
igth
nber
I/ Riprap h
distance 4
K distance
annel
,ic yards
ip
atli
illdozing
■■■■■■■ ■■■■■■■■■■■
■■■■■ ■■■■■■■■
!Len Whh + — ■■ ■■■ ■■■■■M■■■■N
■
WO
u�u■■s�►■■■■■■■■■■■OM
❑ See note on back regarding River Basin
.ocal Planning jurisdiction)

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date G " S-
Name of Property Owner Applying for Permit:
M11ailing .Address:
C►�cc,� .� a,-t L
rj C-
I certifv that I have authorized (agent) %r,'D to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at /lo .? SAD '� ti ✓'< G1E `�"
This certification is valid thru (date) 42 Z3 / /,, % _.
Property Owner Signature
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to /► --cA4< %�%an�q /(i ✓a te s
n (Name of Property Owner)
property located at /(o 02. E n e tg ., i
Pa yt 5 C/`ec (Aiddress, Lot, Block, Road, etc.)
on %� f n o N.C.
Q aterbod
� y) (Cit own and/or County)
The applicant has descnbed to me, as shown below, the development proposed at the above
locatiory
� I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(IndMidual proposing development must fl(l 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.)
1 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)
/ / �
Signature 11
t/�i
Signature'
/7�nn
_L
e Ifz/mo rt
Print or Type Name
/4 a. S r;�. C'r'<ck -Zwtt
_F/i2a�i%
Print or Type Name
/(oL sph`:n9
L'rrck /Cw..c,
Maili Addres
�r,
Madirp Address61
J,-rt-a, /�
W: l� , n �7 0.�
/VT C_ 8 cf 1 t
�t /StatelZ
io.GS'G•a
City/State
Sod--7Y3-/2Sro
a- teGnRneeC.nr, co+�
Telephone Number /email address
Telephone Number
/ email address
Date
Date"
�RevrsedAug 2014)
'Valid for one calendar year after signature'

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to r%c 4ae/ d- 1.141-o(a / �. vwf7t s
(Name of Property Owner)
property located at 16 Z
n f (A dress, Lot, Block, Road, etc.)
on I -f s Crc alC in W. (m;ng�m� N H. Gaw�i. N.C.
�l (Waterbody) (Citywn a /or County)
The applicant has described to me, as shown below, the development proposed at the above
!ovation.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(lnc!Mdua/ proposing development must Ml In descripdon 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.
(P►ooerty Owner Information)
(Adjacent Property Owner Information)
Si nJi4 ,
Si aturf�
,rPy:CAQe4 �.,.
Yvonne h(um��L'
Print or Type7 Name
Print or Type Name
/d A S �', Cr—kL q., c
/58 SF r ,•, Cr<ck .
Maihnq Addrfrss
Maihp Addres
CityCity/State/Zip �r
City/Stat ip
�•bALOaoy m:ke.s�runr> yt,�.rnio�dc.te
W6-4,1-Z.-ysaZ! Y��.So�aol.co.�
Telephone Numberi emai address
Telepnoxre Number i email address
G- �- i7 _
r -/7 -- -- - - -
bate
Date `
Rewsed Aug. 2014)
'Valid for one calendar year after signature'