78011A_Rose, Thomas & Donna_20210210

/k, B C D
XCAMA /'<E)REDGE & FILL
GENERALPERMIT P;jl t1al Rtmsskje Date Plozvlow,;rr-ff'W is"O'd
Aew modification Compkqe Rcllsskil'
As,mthoraed by the Stalt+ of North Calollrit, Dlopat tirient of 1-1111i"O"111(t1l"I Q"'Illty
and Ow co'"Lli Room co's in all Mj:�,j (if envol UMIC111,11 concern pli, scant to 15A NCAC-_ xko, atulfhed
Project Location: County t, v-A
Applicant Name -0,L Street Addressi State Road/ Lot #(s) Y
Address
1 0,17, FA C10- (I 14 -'A
City State Nc ZIPWO-VL� Subdivision V" V1
Phone # (A41) A'_(, E-Mall 161_XVP"`jQ tom' zip 2
Authof ized Agent City I-XA I C) � \,
Phone # ( ­ ) River Basin P?
Affected Cw XEW >�PTA �,AFS )A.PTS Ad,. Wtr, Ballyknat 07-Dunkr.)
OEA HHF 1H UBA NI : � AEC(s): A Y PWS Closest Kill, Wtr. Body i5
A
0 R W y e, s (ng) PNA yes FO
Type of Project.; Activity
Pie, length
F-wed Pladorm(s I
Floawlg pfatformils)
Finger pler(si
1­roin length
number
<j,rlKh-d)Ryrap length
avg distance offshore
max distance offshore 21
Aji noVJUA
(Scale:
Basm, channel (4 , 0, N 1 6 ;� I
+ loor
Cubic "Var(N
Boat ramp VIP,
Boathouse; Boatfill
2
2-
1
Beach Bulldozing
001m, 161?�Sl CD11406e v4,kT�,
A Ull�,
b"t
Ve
Sh,o,eiineLerigih
SAV, nut sore
Moracorairn yes no 3�
no
Waiver Attached no i v l,
ci�
A building pei mit may be required by: See note on back regarding River Basin rules.
Note Local Planning jurisdiction)
Notes/ Special Conditions
�A� ,
1.144 1&L IncJ I-004AI ejA:41'44Ak,1 I .4A.OLV,.,
Srgnacure "' Please read orlipliarice statement on back (j(PerhIlL
Check
(('tZ4/
Pert"" Offlce"s P11111:1,11 N
aar
Signature
2_jjj)j)
Issuingate
C,N),20"L,
Expiration Date

that I own property adjacent to Owner
Irby certify ( e of Property )
property 1°c3ted at d ess, Lot, 8, o%ow
c.)
�6 in Inc�� - , N.C.
on Woe wpr -- - (Cit and/or County)
(watertwdy)
The applicant has described to me, as shown below, the development proposed at the above
cal
lo%
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-
QX
WAIVER SECTION �- tan
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
i
iiio
' to waive the setback, you must initial the appropriate blank below.)
o wish to waive the 15' setback requirement.
not wish to waive the 15' setback requirement.
(Property Owner Iriformati
(Adjacent Ja Property ner Information)
G ;-
. )
�.-SignatureIL
rtutttre* n
Print or T tame O K
1\ /gyp �n Name
mg A ffdres
M .. njUd d -
-�?"�' C. /� /Zip
e! phone Nu r /email address --
.,. dress -s�
- TelY—
Date
e N �b r e ail address
e
l),1,,._ - - - _.
'Valid for one calendar year after sionaniro• (Revised Atio. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
�«�P- — s
I hereby certify that I awn property adjacent to e►Y Ow�ner)
(e of Prop V C�
property located at --
j� ( dress, Lot, Bock, Road, etc.)_• N.C.
on t `�
(waterbody)
- (City own and/or County)
elow, the development proposed at the above
The applicant has described to me, as shown b
locatro
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 orattach a site drawing)
I
9 ! o
tZ,epa�r
e- % P-r—P t(hc
2 R SEC �-- CA
CA 1 --�•
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. f you wish to waive the setback, you must initial the appropriate blank below.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Pformatio )
T '
Si mature P�
Zcr
Print or Type Name
bi-lv o
M rlr ddres
Ciry/StatelZ' ff__
ess
I- -�gia
(Adjacent Property Owner Information)
Signature*
Print or Type Name
Ws
p
Telephone Number email address
Un►e
�L
"Valid for one calendar year after signature'
(Revised Aug. 2014)

123/125 Edgewater Drive, Shiloh - Rose
January 27, 2021 1:781
0 0.005 0.01 0.02 mi
Streets & Addresses
0 0.01 0.02 0.04 k
a
Streets
c= Main Roads
Parcels
County Boundary
Source: Esri, Maxar, GeoEye, Earthstar Geographics, CNES/Airbus
USGS, AeroGRID, IGN, and the GIS User Community
Esri, HERE, Garmin, (c) OpenStreetMap contributors, and th
community