50340D - Washington

CAMA / 7 DREDGE & FILL
ENERAL PERMIT Previous permit#
LNew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
orized by the State of North Carolina,Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC
❑Rules attached.
nt Name { 1'h ' '� Project Location: County •�•-
s Street Address/State Road/Lot#(s)
State ZIP L '7 {—i •LrrjC.. tL--.)rki.�
# ( ) ,v ._i.S - Fax # ( ) Subdivision \N j t , t aJ r_-i= k-)Z-L`)
lzed Agent ,L,E i tr 1 -, City -T tAf.-) i �J ZIP q1
d ❑CW -EW L"PTA ❑ES ❑PTS Phone# ( ) River BasinC}�p E.
❑OEA ❑HHF ❑IH ❑UBA ❑N/A Adj.Wtr. Body11'''‘-`--` U'`
n
❑ PWS: ❑FC: HI
yes /ono PNA yes no Crit.Hab. yes / no Closest Maj.Wtr. Body YV
of Project/Activity t_ i; 12.1--\r•----p -'---J L XT-
is_ I,
dock)length it K Z) (Scale: 1
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r pier(s) -- 11111•10011111MIIIMMIMII«I„11NIPJISII©IMM1MINIMM
i length I I
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number ' i�l iIIiIIIIIIiI
li
p
lead/Riprap length III II
1 f
avg distance offshore
max distance offshore j I f
,channel
cubic yards f
-ampIl
! f
louse/Boatlift
I Bulldozing_ I
1,ILI1 f,i 'Q' !1111 ' 11Iili
line Length C.5.a IIM1E11111111111111 II��i t1�A��MM:EM���M MI
not sure yes no : iiimiimili��ags: notsureyesno - �iorium: n/a yes no,Ij I�fr��l1 11111.1. ,
s: yes no Tj--._ ! IP II 1IU NMI _.
r Attached: yes 'FI¢,D (Thl
MEM
ding permit may be required by: L" 1`35 t -- 1 I See note on back regarding River Basin
:/S tecial Conditionc

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS/BOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to 004,,)\ G _ A 's
(Name of Property Owner)
property located at H00 0 gOad
(Lot,Block,Road,etc.)
on (Y) (,UtL ,mPY)CVA (emu ,N.C.
(VVaterbod Y) (Town and/or County)
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.
r
1/ I do not wish to waive the setback requirement.
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
010
�� i5a �ecv��°
e
Ih),� �dalvvr
Of e- 14)
re 4-vr' l
fvf
Signature
W A7ue
Print or Type Name

C,Le&c
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS/BOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to h,nti)vf1 (,'j 's
(Name of Property Owner)
property located at 000 5 4
(Lot,Block,Road,etc.)
on (11 W Milk- ,in lc)Cl/tar C_OU-(l' , ,N.C.
(Waterbody) (Town and/or County)1
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/boatliffilboathouse
must be set back a minimum distance of fifteen feet (15') from my area of riparian access unless
waived by me.
I do not wish to waive the setback requirement.
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
CX/f
Aen
1.I 0ll
l
6 E)e/4"w)
/11
44-4
Si a ature
Print or Type . e
t/(, ' /)/

(00 110,n 6- ' QCAio / �OcJ) 'Je05-E S ( f Ar)c) 1 ur'r )1-0
Letter of agent
WR, 1��� � '"'� / 1� have retained Mark Clements DBA, Clements
Marine Construction Inc, to make application for any and all permits needed to start
construction on the work requested for our property or properties.
By allowing Mr. Clements to make such applications I do understand that this will in no
way relieve me of any obligations to perform all work according to the building codes of
North Carolina, CAMA, DWQ or any other state and or county ordinances.
5Tt Aft i A- 7W OssMia-r✓ OF T
Print name
Signature 9/13/ÜT
t r' 2 313 3 date
Contact information

CLEMENTS MARINE CONSTRUCTION INC
112 CIRCLE DRIVE 910-270-9110 1726
HAMPSTEAD,NC 28443 fj
Date C/ �/-� /�� 66-30/531
365
Pay to the /�/' ����
Orderof I $
jC�'`'� Dollars B o
First Citizens
Bank
firstcitizens.corn ,,.
For
1:0 5 3 100 3001:00 3 5 3 208 11158ii' 01726
ws
COAS SAL VIEW5. 4.