71876D - Ward

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+CAMA/ ❑DREDGE & FILL P/"� No 71876 A B
§EN ERAL PERMIT Previous permit#
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued YNNd
-ized by the State of North Carolina,Department of Environmental Quality -
:oastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC (5) g, ' 1 I 0 6
��nj Rules attached.
t Name r v `p'1C-.0 N! F-/" Project Location: County if i\-'0 F ate"
15 r N 0 a-�t O iL ,( Street Address/State�Rgad/Lot#(s)
U/ f t State NC ZIP 7g4K5.. I ` !Y . `, k g- .
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�( � � E Mail �
ed Agent p- ✓e L-L ee- pi '\1ICity 4;1/ F. ('t ZIP 1 2f'
❑CW ❑EW ❑PTA WS '❑PTS Phone# ( -"T"--'"— River Basin fr '
❑OEA ❑HHF ❑IH ❑UBA ❑N/A Adj.Wtr. Body w(9S/} IL 9 "J/) Ago r
❑ MS:
yes PNA e no Closest Maj.Wtr. Body / L(c A L �!/
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ier(s)
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distance offshore
DC distance offshore 1
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not sure yes 6, Nt, t ‘kc . WeH
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yes o jP'11.-1'>
kttached: yes ( ,�
t ng permit may be required by: ? i 1"(, `� I Lt I See note on back regarding River Basin ri
Local Planning lurisdiction) _ / / t i /

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: s t'�( � A (,L)P\ R£,
Mailing Address: ,n 10 0/Q. T it 1
if- do( ,,;(&/-11 5
Phone Number: ` ( 0 c5c .5 — 2- 10 `7
Email Address: Im`d s u) I )\✓ c f ( 4 . O rl
I certify that I have authorized ‘ C f fl l
(;. u Y' ( l Z°
A
in(4re Lignent,t>/ uorc_tiDA.
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: (L)�i ((
at my property located at I .ii). i _`.)0 L
in i\ C+ ('"V. County.
I furthermore certify that I am authorized to grant, and do in fact grant permission
Division of Coastal Management staff, The Local Permit Officer and their agents to e
on the aforementioned lands in connection with evaluating information related to
permit application.
Property Owner Information:
71t
Signature
rq 1-7414 W
Print or Type Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to /4 / r/ ,t i ', 44 's
, )0/e -FP (Maple of Property Owner)
property located at ' .) I-(f4 j
(Address, Lot, Block? Road, etc.)
on r�(?�S /L 0014 f?�� , in _. c% /t r� L /% / , N.C.
(Waterbody) (City/Town and/or County)
The appli,ant has described to me, as shown below, the development proposed at the above
locatit
I have no objection to this proposal.
•
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)
sea. ,t, ati1 sea Lo I(
cra'' tiski_r!7 / —
WAIVE SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, 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.)
I do wish to waive the 15' setback requirement.
f I do not wish to waive the 15'setback requirement.
(Property Owner
Information)
Info rm<ation) (Adjacent Property
roperty Owner Information)formation)
.1 i. ei i —4
' , � 1� 'Sifi` re71 )A e_O Sig e /
Pinr ivi-
or 11 �. / Pring�YPe N me�l ` �
"770 t / 4,

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to I1), A / /l . r, , , S 's
(Name of Property Owner)
property located at .>% (72 A) /'it, _' ! kL
(Address, Lot, Block Road, etc.) ,
on /ol). / C0 i1 50 J) , in = 1 r_4._ ( ''i Li , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
V I have no objection to this proposal.
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)
----o 2 0 1.----Di ,4.,
� -\,L,0,e( ect Lod 11
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, 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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Ownerr Informatio ) (Adjacent Property Owner Information)
�k��L��l��� & ctS'intrt14411\. kL-
U �� s Q*
, r- a K tc Ur-
Print or T Na ��
p=x� L L• �j q Print or Type Name �
,i ''' /� .0 i/\ 2S MA M O i'h 11 (Th

Chock
m(Name) Name of Permit Holder Vendor Check Number amount Permit Number/Comments Receipt or Refund/Reallocated
mn] ColumM Column." ColumM Column7 Column6 Column9
same State Employees CU 60811$__400.00 GP#71876D iJD rct.11653
.0 Jade and Cathi Litcher Coastal CU 2415 $ 200.00 GP#77825D JD rct.11629
ie,Inc. Michael Owen First Federal 1392 $ 200.00 GP#77855D BB rctr.11542