Dodge, Randy 76697C

AMA / ❑DREDGE & FILL N9 76697 A B D
ENERAL PERMIT Previous permit#
New ❑Modification ❑Complete Reissue ❑,Partial Reissue Date prevjqus ermit issue
As auth rued by the State of North Carolina, Department of Environmental Quality �/I
and the Coastal Re urces CMeaon pursuant to 15A NCAC
Rules atta ed.
Applicant Name Project Location: County n
Addre LStreet Address/ t e Roadd/LottCity_
Phone iz _=�;
n
Authorized Agent
Affected LJ
CW EW rA
AEC(s): ❑OEA r7HHF ❑IH
PWSL
ORW: yes / PNA yes /
Type of Project/ Activity
Pier (dock) length_
Fixed Platform(s)
Floating Platform(s)
Groin length
number
Bulkhead/ Riprap length_
avg distance offshore
max distance offshore
Basin, channel /
cubic yards
Boat ramp _ I
Boathouse Bo [lift
Beach Bu dozing
Other
Shoreline Length
SAV: not sure yes o
Moratorium: n/a yes no
Photos: yes
o
Waiver Attached: ) no
A building permit may (bee required by:
( Note Local Planning Jurisdiction)r7
or Appli
❑ES ❑w
❑ UBA ❑ N/A
Phone #
Adj. Wtr. Body_
Closest Maj. Wtr.
1L
V5111
1/1 f
(Scale: I� )
e/ on back regarding
compliance
Application Feels)
�
Signature �
Issw g D e Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
R(kyjo
Name of Property Owner Requesting Permit:
r
Mailing Address: 170S Park 1Dr!yN
Phone Number: T� 2 �i `t(i 2
Email Address: t �oc n z �C1 ✓ r^, C'Z4 \
I certify that I have authorized jt✓11G ?CA
Agent / contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits 1
necessary for the following proposed development: 1 •'ts6- w �-�"y ll�J`
at my ' .property located at 'f k �Ur 4 1 V n
in 64v-4e e`e County.
I furthermore certify that I 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 r ted to this
permit application.
Property Owner Information:
-�' Signature
�a�doln� & k'f-6tkc& I
Print or Type Name
t�u7tters
Title
I Su+1el1 ���
Date
This certification is valid through

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I herepy certify that I own property adjacent to e s
r-, , (Name of Property Owner)
pro
on
The applicant has described to me, as shown below, the development proposed at the above
oca
I have no objection to. this proposal.
I have ob'rxLons tfl�tus_ [opos.
DESCRIPTION AND/OR DRAWING Of PROPOSED DEVELOPMENT
(Individual proposing development must fill In description below or attach a site drawing)
vKe'
15
n
WAIVER SECTION .
I understand that a pier, dock, mooring pilings, 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.)
r� 1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) reowxjacent Property Owner Information)
Signature
SiRnatr' Inl n. c �f4lPkil�n ,��t%p0. �/il�th
or
Telephone Number
Date
(Revised 6/18/2012)

ADJACENT RIPARIAN PROPER OW ER ST 7 e cn '
's
I hereby certify that I own property adjacent to "- (Name of Props Owner)
property located at z f "'itJ l
�PI P t (Address
on , A Ttrah .v`Pn�G , in
t b d
N.0
(Wa or o y)
The applicant has described to me, as shown below, the development proposed at the above .
o
I have no objection to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site
cat
ppook�W
ko`Q9
U
e5c'`S��GC
WAIVER SECTION .
I understand that a pier, dock, mooring pilings, breakwater, boathouim
back a minimum distance of 15' from my area of riparian access unl(
wish to waive the setback, you must initial the appropriate blank belQ
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement:
r (Property Owner Information) �grbl�CfljacentPrope
I -
St ature Sign
Print or T N me Print or Type Nara
`M3 �cc.r �riV2 tCa05' Avich
M King Jddrep Me ling Address
City/State/Zip U, C /,StateJZlp
J
Telephone Number T�
Ct
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{ t 4F{ Date

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