50357D - Brown

CAMA / DREDGE & FILL
GENERAL PERMIT Previous permit#
flew ❑Modification []Complete Reissue ❑Partial Reissue Date previous permit issued
orized by the State of North Carolina, Department of Environment and Natural Resources I
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC i
Rules attached.
.nt Name ?� C-`-> +Z-' Project Location: County cDrJ SL-
.k,.�
s Street Address/ State Road/ Lot #(s)
t State i''/ C ZIPS Z C, '�:5S
1
# ( ) - - Fax # O Subdivision
ized Agent City` :�'-� 2T �'T, i \ I ZIP--- �t }
d CW — Ew PTA —ES ❑ PTS Phone # ( ) River Basin lW u Li
❑ OEA ❑ HHF L_ IH ❑ USA ❑ N/A L[ w N
El PWS: ❑ FC: Adj. Wtr. Body i P �� (nat
yes / no PNA yes (nj> Crit.Hab. yes / no
Closest Maj. Wtr. Body - `^ "~" `J
of Project/ Activity rTO ���- `01�L+�`f 1
(Scale: 11
;dock) length
i length
number
lead/ Riprap length 0 j
avg distance offshore it -
max distance offshore Z—
, channel
cubic yards
ramp
louse/ Boatlift
i Bulldozing
line Length DALP
5
not sure yes ( no
ags: not sure yes (:no)
- - -- - -- -
:orium: n/a yes no.
s: yes no
!r Attached: yes no
ding permit may be required by: J V\ +�, G �� ❑ See note on back regarding River Basin
a/ Knee —i r--A;+;^-. 1Z . — V as Cr

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORIN(,PILING;,VIBOATIII F/77BOA'7/H/OUSE)��j
I hereby certify that I own property adjacent to �e47MO
(Name of Property Owner)
property located at '
(Lot, Block, Road, etc.)
on �!=�1 in
(Waterbody) (Town and/or County)
Applicant's phone #:
)Mailing Address:
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (I Y) from my area of riparian access unless
waived by me. (If you wish to waive the setback, you must initial the appropriate blank
below.)
O�dowish
wish to waive
to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Mailing Address
(Riparian Property Owner Information)
Signature
AT..,.. -

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORINC PILINGS'/11OA77,IF77BOAT HOUSE)
I hereby certify that I own properly adjacent to 411��4f4t z ( 711`�l!t)'s
(Name of Property Owner)
property located at
q Th s C
(Lot, Block, Road, etc.)
(Waterbody) (Town and/or County)
Applicant's phone #:
Mailing Address:
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled its by individual proposing development)
--------------------------------------------------------
(Information for Property Owner Applying
for Permit)
� w�1v4�f
Mailing Address
--------------------------------------------------------
(Ripa»an Property Owner Information)
Signature
.8erthc�.Toy �lr — IY)�ll �r

NCDENR 1
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Purdue, Governor James H. Gregson, Director Dee Freeman, Secretary
AGENT AUTHORIZATION FORM
Date ] [`/ 6 q
Name of Property Owner Applying for Permit:
M
ailing Address:
PA. /)#.
V-i //,( /UL oZ 957 2
_ otto- aCuo-
r
I certify that I have authorized (agent) r� r�p �I,, �- 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) q0 55- 0l�
This certification is valid thru (date)
X 11 Y2. " -) I I - /

THE F ram- "�� � � HAS A MI IM BORDER AND UV FIBERS. ABSENCE OF THESE FEATURES WILL INDICATE A COPY. IR;!9"
,RTIFICIAL WATERMARK PRINTED ON THE BACK, THE FRONT Of THE DOCUMENT • L
0/pkgRev 01) ! i�lJil J,_1,i w D 24446994 51709
O0',183
rderOf Date1.1./0:3/2009
Value Valid One Year From Issue, Three Years in CA - Money Order Subject to Return and Service Charge Thereafter)
UR HUNDR170 DOLLARS AND 00 C1 NTS `l x"x x A x az x xit00
Purchaser, Signer For Drawer
uF�F1N3_i0N 1:3R-1ML
Address
For
COVIA PURCHASER, BY SIGNING YOU AGREE TO THE SERVICE CHARGE AND OTHER TERMS ON THE REVERSE SIDE
AONEYGRAM
EYGRAM PAYMENT SYSTEMS, INC. DRAWEE: THE BANK OF NEW YORK MELLON Not Good For More Than $1 e
000.00 sec -is Features
BOX 9476. MINNEAPOLIS, MN 55480 EVERETT, MA Dtails on Back
III24446994ii' i:0110070921:017071L99431B31"