69402D - Wallin

LAMA / DREDGE & FILL �Al I5�
h .1 A B
•EN ERAL PERMIT %� Previous permit #
ew -_ Modification IIComplete Reissue ❑Partial Reissue Date previous permit issued
sized by the State of North Carolina, Department of Environment and Natural Resources j +�
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC I fA . l �y V
❑ Fules attached.
t Name NANI,LN Project Location: County
Street Address/ State Road/ Lot #(s) 0
State ZIP � � ) � -�Su�' \ V
L 11�1) E-Mail Subdivision —�
ed Agent
❑ CwPT
❑ OEA ❑ HHF ❑ IH
❑ PWS:
yes / no PNA yes
' Project/ Activity
-k)length
itform(s)
Platform(s)
ngth
nber
f/ Riprap length_
distance offshore
x distance offshore
cannel
)ic yards_
ip
se/ Boatlift
Length
not sure yes o
um: n/a yes
des no
attached: ve _nn
A ❑ ES ❑ PTS
❑ UBA ❑ N/A
no
City Y�t(j`� ZIP_
Phone # ( ') River Basin
Adj. Wtr. Body
Closest Maj. Wtr. Body
(Scale:' j. ! 4
ig permit may be'required by: j��%� j� ❑ See note on back regarding River Basin
_ocal Planning jurisdiction) i ^ t

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to _4;�CQ PC, UD C<A_ 's
-�
(Name of Property Owner)
�S
property located at 15so b6n �M (P) kJ UZZQ—y (.v ,1--T — vvv U
(Address, `t, Bloc Ro e )
on �� nth in cPivl N.C.
(Waterbody) (City/T wn and/or County)
The applicant has described to me, as shown below, the development proposed at the above
I 2 I have no objection to this proposal.
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)
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
m f 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) (A ent Prope Owner Information)
Signu -D N A , /A L L / / Si rzatur * f,
ITV � V
Print or]?O . A m/ Print or. Type! � PU
Ad�;I;- A.J.J.-L-- ..- ---- .

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Applying for Permit:n
Mailing address: a-C 06
�-��----
Phone Number: d
I certify that I have authorized '
g t /Contractor
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of r tt ,
at my property located at
in Fle-1-1- C� C-V
County.
This certification is valid through 31 Oct- .2c tai
Date
(Property Owner Information)
r Signature
Print or Type Name
Title