76580D - Leak

JCAMA / ❑ DREDGE & FILL • N9 76580 A B
'ENERAL PERMIT Previous permit#
l,New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
Ized by the State of North Carolina, Department of Environmental Quality ' 7- U U
;oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
❑ Rulesattwhed.
t Name i�44 L ❑ � Project Location: County �L4(
Street Address/ Stattee Road/ Lott #(s)
l H 5 T� Sr' l F.� State ZIP 2 7 n! Z
E-Mail
ed Agent
❑ CW
'KW PTA ❑ ES ❑ PTS
❑ OEA
❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes;/no—,
PNA yes / f o
' Project/ Activity J.,O S
-k) length
rtform(s)
ip
4�0�01
a
Length 't /' S U",
um: n/a yes (no/
yes f
___
kttached:s
ig permit may be required by:
_ocal Planning jurisdiction)
Subdivision
city /F / L t`%}�f z I P
Phone # F�ver Basin w
Adj. Wtr. Body q.A
Closest Maj. Wtr. Body
I
❑ See note on back regarding River Basin rt

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to {Z.(o�-r r=. u*k :'R . is
(Name of Property Owner)
property located at a9 2 GayE AV6
e-
(Address, Lot, Block, Road, etc.)
an fat.. in z cZ N.C.
(Waterbody) (City/Town and/orCounty)
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 DEVELOPMENT
(Individual proposing development must rill 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
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wai%
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)
Signature
Print or Type Name
(Adjacent Property Owner Information)
Si ture
0
Prfinl or Type ame

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 14 —'-'Y4 's
(Name qf Property Owner)
property located at ` k Z GA o"J ice.
(A dress, Lot, Block, ftoiid, etc.)
on , in , N.C.
(Waterbody) (CitylTown and/or County)
The applicant has described to me, as shown below, the development proposed at the above location
`L/ 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)
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 wail
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) (Adjacent Property Owner Information)
Signature
Print or Type Name
C ✓w.G'Cc.
Signature
Print or Type Name
-P--- i .J

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Neme or Permit N90der
V..dw
Check Numbw
Check
emcum
Permit Numbw/Commwrts
Reoel t a Rerund/Reetloceted
VMS
C.A-4
Coh—S
CW-6
Col-7
Cok—O
Column9
ons6uctlon, Inc.
Cameron_ Ward
Coastal Bank and Trust
BUT -
FCB
Consumers -
3284 $ 200.00
8298' $ _ 200.00
89001 $ 200.00
5022 Z00.00
GP 0765790
GP i76560D
GPir7+652D - -
P 976534D —
JD rct. 10244
JD rct. 10245
Ben rct. 10420
PA rct. 1077 -
same_
nshvdion Irrc
Ca
Same