66235D - Dolan

',CAMA / -'DREDGE & FILL � �k
A B
3'ENERAL PERMIT 1 Previous permit#
New Modification Complete Reissue Partial 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 I SA NCAC
Rules attached,
t Name_ - - _ - - - - Project Location: County - -
Street Address/ State Road/ Lot #(s)
State -_ _ ZIP
(- ) E-Mail
ed Agent - -- — - -
CW ' EW PTA ES PTS
OEA HHF IH UBA N A
PWS
yes no PNA yes no
Project; Activity
:k)length
itformisi
Platform s
eri s
igth
nber
J! Riprap length
distance offshore_
x distance offshore
annel
iic yards
1p
se; Boatlift
Adozing —
Length _ r
notsure yes no
um: n a yes no
yes no
,ttached: yes no
ig permit may be required by:
-ocal Planning Jurisdiction)
Subdivision
City ZIP
Phone # (_ _ ) _ _ River Basin
Adj. Wtr. Body - _ gnat it
Closest Maj. Wtr. Body
(Scale:
See note on back regarding River Basin rt

NC Divisjor- of C-vastal W1911'. llabltat IMPact "--0'rPut9r -e
2
#:
Applicapplicant:Permit
jze
I
the = _7 All values should rratch the name, and units of rr.easureMent
found in your Habitat code sheet.
TOTAL Sq, Ft. I FIN,kL Sq. Ft. TOTAL Feet F(NAL Feat
DISTURB TYPE
Habitat Name
Choose One
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N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
'_Mailing Address:
I certify that I have authorized (agent) Zj`11,2 to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date) Ziz514�
1.
/2I712-o%5

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to ����< - _ c
(Name of Property Owner)
property located at
(Address, Lott Block, Road. etc.)
NC
(Waterb6dy) (City/Town and/or County)
The appi!gant has described to me. as shown below the development proposed at the above
location.
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)
X �S fi�.l / CGIC L l 41 G
i
WAIVER SECTION
! understand that a pier. dock. mooring p!!ings boat ramp. breakwater boathouse. !!ft, or groin
must be set back a minimum distance of 15' from my area of riparian access unless waivea by
me. (If you wish to waive the setback you must initial the appropriate blank below
I do wish to wave the 15' setback requirement.
do not wish to waive the 15' setback requirement
(Property Owner Information) (Adja nt rop rty er Inf rmation)
Pnnt or Type Name Print or Type Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to I
property located at ��qoD" (Narns of Property Owner)
on (Address, Lot,�loc oad, ) --
�Do in ��/i�/Ili/l P __ �1.C.
(Waterbod) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
lccauor
_\ � I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must rill In description below or attach a site drawing)
/5�
<---4e-�, 0 13/4cic-
/}%W `wall 0h
� z1ay-:11o11, 41.
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
me. (If you wish to waive the setback, you must initial the appropriate blank below.
I do wish to waive the 15' setback requirement_
do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Info tion)
sign toe Sigrrar
Print or Ty Name n Pnnt or T Name
M 7 Mail
iJ7g Ad ss

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