69199D - Rice

ACAMA / DREDGE & FILL
ENERAL PERMIT
A B
Previous permit #
ew Modification Complete Reissue Partial Reissue Date previous permit issued
horized by the State of North Carolina, Department of Environment and
Coastal Resources
Natural Resources
ie Commission in an area of environmental concern pursuant
to I SA NCAC (/-7
,,
:ant Name .jr j�(,�; �A CV In d
s Rul attached.
Project Location: County /r(lf� �,�.•�-C
.ss (' s 5c VY1 ij I� ► - 0'
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Street Address/ State Road/ Lot #(s)
CS
ill t State,) ZIP'41 �50
GGUUA7j1
# (D ( ;0_ 6117E-Mail _
Subdivision `
rizedAglent
City '5hgllQr� ZIP `t
_
ed r ` W KEW )-fTA ES PTS
Phone # ( ) River Basin (IVY"
OEA HHF IH UBA N/A
')
PWS:
Adj. Wtr. Body S'O' V Q f a CND
yes / Po) PNA Al no
Closest Maj. Wtr. Body 1 `� t MA
of Project/ Activity
dock) length L% % 5 L J I
Platform(s)
ng Platform(s)
r pier(s)
i length
number
read/ Riprap lengt
avg distance off ore
max distance fshore
,channel
cubic
-amp
HOO'kFWd1 i✓.4( V-
line Length t 5
Z'Uy' ( ' Chi u��
0� i We ) e; 41n
le l 4
L.
�_d
6V (Scale:
v
l
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t/IAA YY", ["7'11,A&A,
v
�rttnv�,v,ls`� . fix h 4-
`�------,._ 6har to (-h'v" i 4r
not sure yes `t "Y ' v f j'
orium: Na yes o ` �� �Zl( l i' �-
s: t_' no 1
-r Attached: yes c)
ding permit may be required by: t1/y,SVV12 �(�/V�'� ►'�''
e Local Planning Jurisdiction) �—
1
r'� COY t'
See note on back regarding River Basin r
1-4 P . i I t

ADJACENT RIPARIAN PROPERTY OWNER STAT ENT
1 hereby certify that I own property adjacent to ►,ne-4 � AAA* r,i An rl IZ; � -' 's
Property located at 1 5 +4'r v �
of Property Owner)
r,
<- (Addnm
on Cry..? in
(Waterbody)
Road, etc.)
o ife
(City/Town and/or County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above location.
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)
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WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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) (Ada t Prop" Owner Information)
Signalur SI
44I 4 Ri{ C.� _ 7' Ji
t-AyLY
Print or yp^ee Name Pmd or Type Name
T
'� Il niXi t' t )rY�G r ty 5f
Ma�lrng Address

noPL
ETE TNIS SECTION
1, 2, and 3.
-vimand address
Tatum � the reverse
■ Attach this cabackrd to you.
or on the front if the MaifPiec-e,
1. article Adder to:
i
9590 9402 2344 6225 5659 07��'
711 015 1730 00130�6865
Fcxm 3811, J* 20I S pSN 7s3o (12 _
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A St�aturs
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B. R bS' (I'nnted Name1 �
e of Delivery
D. ff is
YES, euvery ass dHf h°^ier�t ttam 1? [3 Yes
enter 6311v ,,, amass b..I__ ❑ N.
3. Service 7y� -
11 �d 0 Adult Adult � Ramat` �e'vea ,
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0 ore �C'Mod Ma
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Ma"
0 Retian pw for
a RASU'kct6d
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tic Return Receipt

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