68547D - Williams

CAJNAA ;(' DREDGE & FILL 3I 5 f �-
3ENE"L PERMIT Previous permit# A .-
New -Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
sized by the State of North Carolina, Department of Environment and Natural Resources (
Zoastal Resources Commission in an area of environmental concern pursuant to 15A NCAC 1 O©
' R ❑ Rules attached.
it Name ry i' 1d S Project Location: County p &44o<<iJ`
Street AjAddress/ State Road/ Lot #(s)
State N� ZIP �43 �%`' �/-� f`��"IC'o^J
ail
:ed Agent '' ) ►`ti-
❑ CW )M EW PTA /*ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
yes PNA yes no
f Project/ Activity
; distance offshore —&-,
iannel
e Length tf=
Subdivision
city ZIP `-O`t
Phone # ( ) River Basin
Adj. Wtr. Body V1 f A "0 a — nat
Closest Mal. Wtr. Body
(Scale:
ig permit may be required by:
Local Planning jurisdiction)
❑ See note on back regarding River Basin n

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Name of Property Owner Applying for Permit;
Mailing Address:
I certify that I have authorized (agent) � JP ' �% � �� to act on my
r behalf, for the purpose of applying for and
obtaining all CA.MA PermW necessary to
install or construct (activity)Cc l
at (my property located at) 14
This certification is valid thrn (date)
7
Property owner Signature Date

ADJACENT RIPARIAN PRQURTY OWNER STATEMENT
n
i hereby certify that I own property adjacent to ,4z-,c{ %' `s
(Name of Property Owner)
property located at 2
(Address, Lot, Wock, Road, etc.)
on '_ t: Cs in N.C.
` (Waterbody) (City/Town and/or Countyy
The applicant has described to me, as shown below, the development proposed at the above
location.
y"' I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(kKgvidual proposing dovefcpment must fill in4escription below or attach a s#e drawing)
QpprO x . qO'edge- o 1'`, ,Pro�0erf ya hf Cree�
WAKR SECIM
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
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)
i
Signature
Pa,71 cr Type Akww
Mailing Address
(Adjacent Property Owner Information)
Sigjtatur
Pr6it c Name
MaOino Address

ADJACENT RIPARIAN PRQPERTY QMER STATE, Ni
i hereby certify that l own property adjacent to � '= �� � _ r&
i7W of ProRerrty Ourtres)
v
(Address, Lot, Block, Road, etc.)
N.C.
(Waterbody) (City/Town andlor County)
The applicant has described to me, as shown below, the development proposed at the above
I have no objection to this proposal.
! have objections to this proposal,
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual ptopos ng dovwk went ~ M #tt desctipfto below or attach a site drawing)
a /,Pro10 fr al6c- f e/r e,,k
AIVER SECT
l understand that a tier, dock, mooring pilings, boat ramp, breakwater, boathouse, lilt, or groin
must be set back a minimum distance of 16 from my area of riparian access unless waived by
me. (If you wish to waive the setback, you must initial the appropriate blank below.)
Vd/ (do wish to waive the 15` setback requirement.
l do not wish W waive the 16 setback requirement.
(Property Owner l formation) (Adjacent P Information)
1^l .
Pint or Type Norm Print or T

1109
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