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GENERAL PERMIT Previouspermit-#-'1-So
• EI-New- OModificationComplete Reisue OPartial.Reissue Date-previous permit issued i_ ,1�.p•cl
As.authorized by the State•of North Carolina Department of Environmental Quality
and the=Coasts(Resources Commission inan area of environmental concern.pursuarit to I5A NCAC ,.1� .1 .C7..-
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App'cant.Name h
❑Rulesattach
'�:-.•(- -• Project anon County � �e� -:Lac
• Street Addressf State Roadf Lot#s:
Address }
City e • AGt r t31 State ZIP;O •a-' " -1Z 4 lu -Wvl
Rhone#4 )r(rq. ;- a: E•Mail' . •
-... : Subdivision; = r -
AuthorizedAgent ( rl City • , s 14t �je& d" ZIP
='C14- P'TA DEs ❑PTS: Phone# ver Basin
Affected: ) /'�,, �. y��1rt1'tr
AEC 8 OOEII HH6' E77H? pUBA ON/11: ]� c'Y tL`,f/{ /
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OPWS
Closest Wtr:Body r �:•
ORW; yes'/�no .. PNA Y�l�; Ma'-- I� - � � _
Type'of Project/Attivitp6.v. . .S 1.1n S' w 1l +<.)c 5 is - �� �Y (S l' r gyp' )"` tale: •
Pier(dock)len
FbcedPlatform(s) r i.; i II fi i i - I '
j,! t• ' L — Seac;04-.vs �?f*It., r 1 i {
i. FloadngPlatform(s)tb 'L. i /(!,.,_;,� ` �--i' { I ., �— ;
Fingerrpler(s) '.''''''''„'-i---'." i' e, aw '__ E I.. Q,i i 1. .l*`r— -_ T, t.
Groin'l ,,,. :
ength . " F � i { _
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number. ' I 1 i I__— r !_ :.� } i •: i - I 1,. t t ,; i ". k
_ = Bulkti'ead/Ftiprap length i_Flii - 0.��� `({ r '
avg distance off ores -"
max c4stance offshore._ __ r Y A - ' -
f i i,
Basin;channel
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• cubit,yards- 9,t� - c r /�c1
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a ' ' r- .BoatramP. . L3'4 3 ,u i! 1 iBotou .i L . i. $_1%. r-- ` -- - c. .
Beach Bulldozing F 1 i . f
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Other' •-}-- ` =-- i i: II
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Shoierme.Leng hAd rjC7 r e.- .-__ i i_- '-G,'tV‘� i'l.-) ; - i .i}i
SAY notsure yes no ' : ,,��r_ ? i _ !
Moratorium: n(a- yes ° l4: i } �` 2 citi ce,vw, flit, Ph'=4 T t --
Photos: - 6'.6:4' i- P!� _'k' jZe 1 .pEYr4�lf t.i. �
Waiver Attached, //''"�� S '
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Abuilding.perinit may be required by - r i- V.I. t/ ,N/� a See note on back regarding;River.Basin rules:
(Note Local Pianrnng>f unsdiction) tl J �� Q (� �� .
Notes/Special Conditions BCi n.l.a'UI1, ‘c�1, Vt -�'1�f/1%P+" Y.?i+_Livi!` ' -
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Agentor', ph' Pri . d:same L •• PermitO icer's Panted Name •
Signature 114Pleasereadcompiiancestatementon,backofpermit." Signature- •
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Application Fee(s) Check# Issuing Date Expiration Data '

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AGENT AUTHORIZATION FOR CANIA PERMIT APPI_H . T,L)N-
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to cint on my h=-sha:-F for the purpose of applying for and obtaining al', CAMA
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; furthermore certify that I am..RLthn;1'7 ed to grant. and do 75 C grant per-i.ss!o .
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CERTIFIED MAIL • RETURN RECEIPT REQUESTED
' DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: 1 'iRY z MA8Okn.,
rri�d ti Oft.) W b 5 -0 fL 26Ygt)
Address of Property: 7
(Lot orS�t #,-Street or Road, City& dunty)
Agent's Name #: Ld .LiJ Mailing Address: 1 d
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Agent's phone#--. "f�- � 6- t6'� � � f
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I hereby certify that 1 own property adjacent to the above referenced property. The individual
1R applying for this permit has described to me as shown on the attached drawing the development
-N`b)� they are proposing_ A descrivfiert F ravvinri. wifia inner sioris.: trill&be-provided Wihh-thts:fetter.
cLAA I have no objections to this proposal. I have objections to this proposal.
ff you have objections to what is being proposed,you must notify the Division of Coastal Management(DCM)in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington,NC, 28405-3845. DCM representatives can also be contacted at(910) 796-7215.No response is
considered the same as no objection if you have been notified by Certified Mail_
WAIVER SECTION
- ° c` ' I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
Y; �' 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.)
1 I do wish to waive the 15'-setback requirement.
i
I do not wish to waive the 15' setback requirement.
S1a4c
(Prop ner Information) (Adjacent Property Owner Informations
Si tore 2441(7, glikik--
Signature
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Print or Type Name Print or Type Name
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Mailing Address - Mailing Address
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City/State/Zip City/State/Zip J
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Telephone Number � Telephone Number
f fi111/1 RIO DEC 0 4 tiguV 2/6
Date Lau
®CM Wii IMIN fd:.". _. Revised E• 1G,-2;.._

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