69306D - Stafford

6}CAMA / . ,' DREDGE & FILL
GENERAL PERMIT
)New DModification ❑Complete Reissue
❑ Partial Reissue
A B
Previous permit #
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
Rules a hed.
t N 15;C! O Project Location: County �14 f D
6 107 Street Address//State Road/ Lot
t'# s)
/ State ZIP yyS LP/L,'� 6
�?I)Z �ZE-Mail
ad Agent
❑ CW )MM A El ES ElPTS
ElOEA //❑`"''HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes / no PNA yes CnoD
Subdivision
City %!/� / ZIP �'� I
Phone # ( ---j----" River Basin
Adj. Wtr. Body `
Closest Maj. Wtr. Body ap-t
Project/ Activity
tform(s) MEN No' 0 MEN
IEEE ENMEEE�EIINMNN
igth
\,
I/ Riprap length
distance offshore
c distance offshon�
annel
,e/
ozing
O
Length -
notsure yes
l
Am: n/a yes
yes
ttached: 147
g permit may be required by: %✓ T i�/ ❑ See note on back regarding River Basin
ocal Planning jurisdiction)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that 1 own property adjacent to Circa 5����fZ?� _ s
( me of Property Owner)
property located at t.Q ) D �-} "r c e_j_
(Address, Lot, Block, Road, etc.)
on SftUTYIf)a(_ CJ in EU r C 1 a N.C.
aterhody) (Cltyff wn andlar County)
The applicant has described to me, as shown below, the development proposed at the above
I have no objection to this proposal.
I have objections to this proposal.
2
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must W i» description below or attach a site drawing)
WAIVER SECTION
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 16 setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (A*ceA Property Owner Inf ation)
Si ature
Cx z-Ca M:W-J
Print or T pe Name
tjlul CP
t7ing Addle
City/statelZip
r{5,5}a�r
Telephone Number%ema►1 address Cam`
S. '
Print or Typ. j S e�� .4 e. 4
C7
M Addre . �s
a.
Citylstate' p qN- 4-61- 4A7C) l �r�fc�nr�ct.5 roc ��a��'":.ccv
Telephone Ngbe /emaiii address

f- nn n nr•_pr
L l.� � . � v,9163474399 DMS No. 5618 P. 1/1 82/
ADJMUff _RIPARIAN PRapr OWNER §I,�fl�NT
I hereby cerM/ that I own property adjacent to •S
t"r1 ( me of Property Owner)
property locataki at "�
on c7 � �.rD (A►ddress,B1oU Rt etc. C
( �� N.C.
(Wat&body)
(Ctry/t andlor County)
1 t has described to me, as shown loalow, the development proposed at the above
n.
1 have no obiection to this proposal_
1 have objections to this osal.
.,� prop
DESCRIPTION AND/OR F�RAWING OF PROPOSED !}k'VELQPIVIEI�T
/ (Individual pr *sicq de
►A f i�IFra.tisiip�Oi; Delaw ar aftac�r g sfte drawing)
YJAIVIER SECTION
I understand that a piw, dock, mooring p*ngs, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distarto of Is, from my area of riparian access unless walved by
me. (if you wish to waive the setback, you must Initial the appropriate blank below_)
l do wish to waive the 15' setback requirement.
� 1 do not wish to waive the 15' setback requirement.
(:_W
r Mfvrrn$tlort) (Adjacent Pro
V PQ►tar er Ittfornratlon)
SY e S M
LA
n r ,
Pliat or T10q N" P1W or Type N
© Ic
nWflng d ss g A

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: re r
Mailing Address: U 10 � UtrI � e+
Y---F C I
Phone Number: cfig. D) s. S-7 S a
Email Address:
I certify that I have authorized i)IfYW k-nYIL-H , LienfI+ MUYI
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
in County.
I furthermore certify that 1 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 Owner I
IAV\ Aeis�('-Yne .-
Title