54414D - Pender

DiCAMA / DREDGE & FILL
GENERAL PERMIT Previous permit#
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
orized by the State of North Carolina, Department of Environment and Natural Resources -7
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
p . z les attached.
t Names Ci j,tJNfProject Location: County Yt
ss roaoxy Street Address/ State Road/ Lot #(s) LJ7- Zq
/Za4w State l\k-- ZIP � `�.� -it iV L L j,1 `"7}Z. -P /2/JL
'# (710)Fax # ( ) Subdivision % L�/ S(t�(1 1"L LS i-7 S
fted Agent if'ti141olzolfyn City tl 'ccy w v'I!VT ZIP d ElCW ElEW APTA ❑ ES ROTS Phone # ( ) River Basin C idtv f
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑ FC:
yes / no PNA yes t Crit.Hab. yes / no
Adj. Wtr. Body " (Fit Ana
Closest Maj. Wtr. Body C/T& / z=
of Project/ Activity /" L J1Al" }LT _ P V , K q-w_L d7rfa yu,'3"7t'iZ-
(Scale:
dock) length
length
number
ead/ Riprap length
avg distance offshore_0
max distance offshore
channel
cubic yards
amp
louse/ Boatlift
Bulldozing
line Length
not sure yes
ags: not sure yes
:orium: n/a yes
s: yes
r Attached: yes
T6
,,fro,
v
ding permit may be requires

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WDENR '
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Eaves Perdue James H. Gregson
)r Director
AGENT AUTHORIZATION FORM
ate: (')— - q - e, ?
ame of Property Owner Applying for Permit:
railing Address:
hone Number.
Dee Fre
Sea
certify that I have authorized (agent) A&x c- -I-AVLA b -a 1 w 0 to act on my
chaff, for the purpose of applying for and obtaining all CAMA Permits necessary to instaH or
)nstruct (activity)
t (my property located at) `K 1~• -c -'LO 4-" 1-
.[ -I -- IN 1-5-7— o f—? 9W 3
TIAt
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his certification is valid thru (date) 2a/0
I.
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ADJACENT RIPARIAN PROPERTY ONVI ER STATEMENT
I hereby certify that I own property adjacent to 11) s
(Name of Property Owner
property located at
(Lot, Block, Road, etc.)
(Waterbody) (Toidn a d/or County)
Applicant's phone #:
4'(avf y'. t 2 ae
Mailing Address: Ii a / '�'` r
� 3T,4Y
has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
DESCRIPTION ANWOR DRAWING OF PROPOSED DEVELOP:
(To be filled in by property owner proposing development)
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(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
Mailing Address Signature

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
�,l rt�LY
I hereby certify that I own property adjacent to '419 's
(dame of Property- Owner
property located at L- o > �`71- _
/ (Lot, Block, Road, etc.)
�L
un _ � (�44 / P"y, �� er. inyGK
(Waterbody) (T n aid/or County)
Applicant's phone #: `j o S 9 l Z w
Mailing Address:
i-he has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal_
DESCRIPTION A NOR DRAWING OF PROPOSED DEVELOPMtY't':
(To be filled in by property owner proposing development)
;��hL �� > /1 /liC?�Q/'��L C�/✓,t:1 % %C,/%�s CIS��"i^.%G �� i �,/�fJC'' %t'C�/%�v�
� �•_-GL... �,�ii'l%�cs� Dl/E Tv i�TGi� ,� �,/E :�' l��/�"�S.
P i _
---------------------------------------------------------------------------------------------------------------
(Information for Property Owner Applying (Riparian Property Owner Information} /
for Permit)
Mailing, Address Signature
City/State/Zip
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Print or Type Name
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DATE
PAY THE
� ORDERER OF $
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