69299D - Turner

`QALMA / 1 DREDGE & FILL �'3v 5 A B
GENERAL PERMIT Previous permit#
1New L_iModification ❑Complete Reissue LlPartial 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 15A NCAC
r'— ❑ RLObsattached.
t Name a '� % v r7 Project Location: County 64 5—/ "') CO
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StateNC ZIP
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f
ad Agent
❑ CW (DW /AWA TaS ❑ PTS
ElOEA /❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes /( PNA yes �0, )
Project/ Activity
:k) length
is yards
Street Address/ State Road/of #(s)
7
Subdivi ''
City (/✓ ZIP
Phone # ( ) River Basin
Adj. Wtr. Body + o <'✓= i r
Closest Maj. Wtr. Body V-0t
(Scale: / biz
g permit may be required by:
.ocal Planning jurisdiction)
❑ See note on back regarding River Basin

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ADJACENT RIPARIAN PROPERTY r)imitiER STATEMENT
I hereby certify that i own ;property adiacent to s
.property located at (Name of Property Owner)
(Address, Lot, Block; Road
on in , etc.)
(Waterbody) (City,,Town and/or County) N.C.
The aPplicant has described to me, as shoom beii,w. the development Proposed at the above location.
1 have no objection to this proposal.
I have objections to This proposa'.
DESCRIPTION AND/OR DRAWING OF PROPOSER DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
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 1f>alVa y me. If you wish i� Vva1VC
the setback; you must initial the appropriate blank below.;
�(N i 1 do wish to waive the 15' setback requ€rement.
1 do not :h>ish to waive the S' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
-77
)
Signorure Jib;�iur 2 `
Print or Type Nam.e ; ,; gin? or Type ?+,came
62 Zlc t 72 +Zli 1 13("-r v n S_ ii 1_ J

ADJACENT RIPARIAN PROPERTY OwN-Eg STA T Ei47ENT
I hereby certify that 1 own property adjacent to
property located at
on
(Waterbody)
(Name of Property Owner)
(Address, Lot, Block, Road, etc.
in
(City/Town and/or County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above Iccation.
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 descr/ptfon below or attach a site drawing)
y
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 waive
the setback, you must initial the appropriate plank below.)
PJ's I do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
Signature Signat-ire
C is . 1�)O rc f K I11 !f �L
Print or Type Name Ain or Type Na
&J- &, Sd nQ/ St

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit.
Mailing Address: 10 9e.k 7 a
Phone Number: 7/9- _�-23 32
Email Address:
I certify that I have authorized i i�� �U/`rST&-,((-7'10,if
Agent' C'ontractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: f UL z-1, I)
at my property located at ,INte-D �7-4c�&-7 (7/ 7v�/f�
in P/JS caj County.
1 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 Information:
Signature
4,5 - I, e-,-- 4 e, -
Print or Type Name
Title