69425D - Waterside

CAMA / ' � DREDGE & FILL I, A B
GENERAL PERMIT Previous permit #
RNew '--'Modification ❑ Complete Reissue ❑ Partial Reissue Date previous permit issued_
rized 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
❑ ules attached.
it Name 1� C� �V j� P r S i�G7 [ C Project Location: County 0 � 6 i I Cy 1P. V
G Z N • SGti 1 �'r�/ 1� �'� Street Address/ State Road/ Lot #(s)(17 �(�{
fir1S}1 61�1 State N c ZIP)
t (� l?j— E-Mt fail 1 bCll S @ si t�l`J. f 1' • C 'Subdivision
:ed Agent 11 oni v1 ND�' IVl 1��( city M , �t 11 Dl,� � (f'( ZIP �C
❑ CW �1EW X PTA ❑ ES ❑ PTS l NPhone # ( )� 1 V , River Basin
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A 1II Adj. Wtr. Body nat
❑ PWS:
t *� notf D�/ C Closest Maj. Wtr. Body
yes //no/ PNA yes11
f Project/ Activity Y=bt1k±j , L l I he Dc al I j f i
1An shu e
ngth
■NE■n�on�r�■■!
1N■■■�u�Ni■
�itn■r�r►sue■■■■■■■■■■�
■■■■I�Istl!■Nt0■��I1�■■
■mil■t�i■■■■■■■■■■■■1
1/ Riprap length
■■■■ITfrUMV111■11■■I�►_■■i1
■■//■■■■■■■■■■■■NI
_x distance offshore-
iannel
■■■■u�w■■■1
■■
.■..
■ri■
■�■■■N■wNN■■■■■■■1
■■■■i!��,:JJ■■ti■i■l�lii■■■■E■■■1E11►1■■■■■■■■■1
yards■■■■IL,�'1'liil■■11■■■1
�
■■■
■■'E■�E11,tiLi■1<:�.7■■■■■1
■■■N■■■■■11■■■IN`■■■■�1■i�J�1anR,►
Er■■■■■■1
■■■E■■■■■I
INN
OI
I
■
■■
■i1■■'1,1�i1'N■■■■NEON
■■■■■■■■IIAO■INI■
■■■1■■EWWWOO■■E■EEN
■■■■■■■■■NI
la■■lNIEO�3
■ND/■NEE■■N■■■N■■N
■■■■■■■■NII�iiE1Nl�■E�
■■AN■■N■■■■m■■EN
ON■EE■EEN■11E■O111NE1M
■■■■■■■■■N■■■NON
■■■■■N■■■Ilc�■■111EE�■
■■■N■■■■f1//!�11!■N
■NONN■■ONNIlLRIONI
NI
N
■�
■■■■�N■■w11�I�Il'.�Z3:!l1JWIli■N
- Length
not sure yes
■■■N■■!lQ�1►rNlI■■OINI■ii
■I��l1.itliilW■■■■■N■■■■
ON■Nlll�i7iAir1�71111■■il�I��/
ii��ilirNJ■■■N1�1�■■■■�■ON
iurn: no yes no
lid",
a!=�;_�::::
,;"
CNN■N■■■..,.►�i1l�.a�■■�
ig permit maybe required by: �rY i/+��'1� 1�l i� L� ❑ See note on back regarding River Basin ri
Local Planning Jurisdiction)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 42t, / f Ile
(Name of Property Owner)
property located at 30 � L.✓ ��� c , SOI .
(Address, Lot, Block, Road, etc.) v
n �A,,/h,ti , in 1
on �ar� �S C"
(Waterbody) City/Town and/or/county)
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 DEVELOPMEN I
(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 bac
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wa
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)
L-2=
Sign
sit Cc /L/o .r
Print or Tvoe Na(ne
(Adjacent Property Owner Information)
Si r�
Pry o Type_Name y��

I hereby certify that I own property adjacent to �
property located at i D x- U'I t
(Address,
on k 5 C..�� in .
(Waterbody)
LLL,
Property
Block, Road, etc.)
e -1C.
(City/Town ands r County)
The applicant has described to me, as shown below, the development proposed at the above location.
1 have no objection to this proposal. ✓
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must NN In description below or attach a site drawino
Ct
eel 'SAL 4
(0.,);^t a'yta.c-�'e'A
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.)
MT I do wish to waive the 15' setback requirement. /
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
..� ' l ff (Adjacent proope/rtty owner inrormsuonj
ttlb Wa�tiSu�►� � �c4 44-li
SI ature Si Wfure
id�chael Travis
Print or Type Name T Name
►� �� t I'MrC Pilitary Cutoff Rd., #314

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: (Vf (�" , 0g Q.�'(
Mailing Address:��
Z-
Phone Number: Lo 0 4 S
Email Address: �b ACr s7" 07 �� n U - r r C o t .
I certify that I have authorized
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: Aoc'cy L ; 4 r
Coe r—LL tx 1 z.v5 T-o v�i -
at my property located at 361
in Vvi C Q c �."County.
l furthermore certify that l 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
ly�
c�v
Print or Type Name
m cgV - C
Title