76806A_Peele, Louise_20200806

"
YCAMA / 1-6REDGE & FILL NO 7(1 ()) (29 g C D
GENERAL PERMIT Previous permit #
-New .Modification .'Complete Reissue Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality -7
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
IKules attached.
Applicant Name i! p/,,,4 , pat; Project Location: County yr 'f+ cK
Address �$2 j i� S h..cc Street Address/ State Road/ Lot #(s) j.$� 1:-14:<_o� d
State VA Zit?��itS.I__
Phone # (7S-;) ?V� - U$3 $ E-Mail Subdivision
Authorized Agent ._._t3CLo L.. PLO k � r-ci City _ la. Vt ZIP
CW �£Vv ✓PTA AS PTS Phone # ( ) River Basin `_c.5� R
Affected 5
AEC(s): � HHF IH USA NIA Adj. Wtr. Bodytdt,'+V 1t na" man_/unkn)
PWS: _ C�
— r'IncFer Mai. Wrc Bcxfv
ORW: yes / nR j PNA yes no
Type of Project/ Activity �c l,,�+. iL t IkJo , ud
s_ (Scale.
Pier :'dock; length _
Fixed Platforms) Ac3�
Floating Platforms) r r— Gfitl t r-- EK ter s r+fic j f i
Finger pier(s) _ ...._ -
Groin length
.......
number -- ---- )- - -
Butkheadf Riprap length ISO'
avg distance offshore a'
nw distance offshore
Basin, channel 000000
r
cubic yards RtrQ #
Boat rang ti
aoathousw soattift
Brach Bulldozing _ _f
Other
r s
Shoreline length
SAY: not sure yes �n3�Ct t
�J
t•"oratonum: �� es no
Photos; no
waiver Attached: yes n
A building permit may be required by:�(� + `/ See note on back regarding River Basin rules.
Note Local Planning jurisdiction)
�y,�
Notes/ Special Conditions
Agent orApplicant Printed N rn" "1
wc,
Signature "Please read compliance statement on baJ�of permit*'"
Applicatton Fee()} ChecK #
P�;L
icer Prir red Name
P
Signature
issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Pese'I -P
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
ysz 5 . r_- Kt, Jz_J .
ir�iG_ I-6QGC11 . V, a- 234
Ul
`2:2) _2i 01ZV
Agent / Contractor
;l. c
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: �� +�}-G // D l,e�.y c_ fq
at my property located at /172, ea O4-k /Zc) ,
in 6UVrityAC' County.
/ furthermore certify that / 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
Print or Type Name
Title
Date
This certification is valid through I i I
Received
AUG 3 - WO
D EC

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Lit 54- P.e'd-k OL s
property located at SZ Q1i -)* R J
(Name of Property Owner)
60
� r (Address, Lot, Blo , Road, etc.)
on (_,U✓/i C ov in ��(—o.U- , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loca
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(lndividLat proposing doveidpenefrt must IN in dW fpt/on below or attach a sine dowfng)
ocl
kp
L �-t4vIN
qA',' � �&<<
�
WAIVER SECTION
I unders and that a pier, dock, mooring pilings, boat ramp, breakwater, b athouse, 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.)
N l �l �- I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Informatio
n) / (Adjacent Property Owner Information)
V ' ' 7 ( t'� -
Si tur Signatu e .
Print or T e Name Print r pe Name
M ling I ddress Mailing dressAle 2:7,73,'i 03
C /Stat ip City/State&ip
zd-7 -"z6- / 13«c�he, / .�is�n law► . '!:�; 7
Telephone Number/email address Telephone Number/email address L
ate Date'
*Valid for one calendar year after signature* Received (Revised Aug. 2014)
hVJ r) CULO

!R!PSRC100;EXIT;!R!MTYP99;EXIT;!R!spsz6;stm0;exit; deceived
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT )CND -EC
I hereby certify that I own property adjacent to LUt-Z 54- Ve¢ d USL g
property located at P $Z [ f 1; ,>4 (Name of Property Owner)
/f( (Address, Lot, Blo , Road, etc.)
on (�✓✓I'4vU� S+�u�d , in 4,JA , N.C.
(Waterbody) (CitylTown 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 nr000sa[.
I 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)
P,�G
WAIVER SECTION
I unders and that a pier, dock, mooring pilings, boat ramp, breakwater, b athouse, 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.)
N !A- I do wish to waive the 15' setback requirement.
IN ►t" I do not wish to waive the 15' setback requirement.
(Property Owner Information) // (Adjacent
'/ Property Owner formation)
Si b Gfill Signature* /r f.,o
Pnnt or T e Name Print or Type Name
b ! s2 V eazQ G1 x (ZYZ-
)V9alifing ddress Mailing Address
r N C 2:-713 re VA- 731-A"Ll ✓t z S�`c
CftylStatefZip / City/State2ip
Telephone Number/email address Telephone Number/ it address
1 2DZa -- ��
ar�Z7
r-- - Date*
(Revised Aug. 2014)
`Valid for one calendar year after signature"

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