86179A_Jennings, Sean & Danielle; Shillings, Andrew_20211122

`OUT4, ❑CAMA ❑ DREDGE & FILL N9 86179 A s C DV
K-1 " Y
GENERAL PERMIT Previous permit
Date previous permit issued
❑ New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
15A NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name
Address
City State ZIP
Phone # ( 77�) 2L.
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Email 1 1� { 11 (` I Subdivision
City ZIP
EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (nat/man/unk)
Affected ❑ CW
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
Shoreline Length
Access Length
Pier (dock) length
Fixed Platform(s)
-
i
Floating Platform(s)
Finger pier(s)
Total Platform area
Groin length/#
4 nBulkhead/`Piprap length
Avg distance offshore a
Breakwater/Sill
kl!ista / length
i
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
v
Other
SAV observed:.
yes no
Moratorium: ` n/a
yes no
Site Photos:
yes no
Riparian Waiver Attached:
yes no . t
A building permit/zoning permit may be required by:
Permit Conditions
(Scale: )
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial) �' t
r 1�
'r
Agent or Applicank PRINTED.Name,-
Signature "Please read compliance statement on back of permit"
Application Fee(s) Check #/Money Order
Permit Officer's PRINTED Name
Signature
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 4jee_w j
Mailing Address: 18 On e / L_anen
%QqCle_6� AL .Z7 `L,(&
Phone Number: 7 SS 7 — 2_�5-7 ->� 'I !2
Email Address: 096sze4„J< a-,-i ,
I certify that I have authorized r'L�[S Gt t �3. (&h4 l 5-
Agent / Contractor
to act on my behalf, for the purpose of applying for and nn
obtaining all CAMA permits
necessary for the following proposed development: ;6r-c f/' l +�cw
t (' I(Zq P"'e.i
at my property located at 41.3(y., %U .
in (y6, ' ,4C County.
I furthermore certify that / am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
V Signature
!N . i im
n Print or Type Nathe
Title
Date
This certification is valid through 12- /L31 . / Za7j

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to A(14ew StiWI -o t s
Name of Property wner)
property located at PY
I� 'I I (Address, Lot, Blof Kk Road, etc.)
on U1o44 :rS Lu,/ , in <.crra(1, /yC N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
to t
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)
S
(ana(
�f tJ
lip
1 #*4
4+34 ��� I yT(o r►'1�✓zW�
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 Owner Information)
L���LA a'mj_�
Telephone NNu�mber/email address
Dle
ate
8e,tc-L
*Valid for one calendar year after signature*
(Adjacent P
Owner Information)
Mailing dress - 1�
X 0 !o
Ci4vstate/Zi ([2GG'',
Telephone er � aiaddress
�73
Date k --- —
(Revised Aug. 2014)
,3Z7

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
YMw4- l,' C►�t.e ✓2 a-
�27
krw Nc-
A, slgnatu
X �'
B. Rec W by (Printed Name)
B. . _
❑ Agent
m
D. Is delivery address different from item 19 Ly Ye:
If YES, enter delivery address below: ❑ No
3. Service Type
❑ RgMail Expresso
i
❑Adult Signature
❑Regististered Mailrrn
(II'I�I')
I'II
ICI
I I I
I III
I III
II
I ��
I I I I
II I I
I
❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
9590 9402 6354 0296 4798 09
j�ertified Mail®
❑ Certified Mail Restricted Delivery
Delivery
❑ Signature Confirmation-
❑ Collect on Delivery
El Signature Confirmation
2. Article Number Transfer from service fabefl
❑ Collect on Delivery Restricted Delivery
Restricted Delivery
7020 2450 0002 3104
0743 testricted Delivery
PS Form 3811, July 2020 PSN 7530-02-000-9053
Domestic Return Receipt

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