Brown, Tommy

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No. 75794'
GENERAL PERMIT
Previous permit#
New ❑Modification ❑Complete Reissue ❑Partial Reissue
Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
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and the Coastal Resources Commission in an area of environmental concern pursuant
to 15A NCAC
r$lRules attached.
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Applicant Name I r� / i (�/ 4 1 i 1 /)
Project Location:
County_->> !
Address l �- l �;�� ��! > ;��
Street Address/ State Road/ Lot #(s)
City " �(:( u State '; ZIP
7
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Phone#(��;j) ��� E-Mail
Subdivision
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Authorized Agent 1 7
City
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f r \ I I/ ZIP_
�O CW j]EW EPTA OPTS
Phone# ( )
River Basin
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�19.�5
Affected ,El OEA ❑HHF fI IH ❑UBA ❑N/A
AEC(s):
Adj. Wtr. Body
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man /unim
(nnat,/1
El PWS:
Closest Maj. Wtr.
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Body
-
ORW: yes / no PNA yes / no
Type of Project/ Activity , '?/- 4 � >✓
Pier (dock)length _
Fixed Platform(s)
Floating Platform(s)
Finger pier(s) �
Groin length
number
Bulkhead/ Riprap length %
avg distance offshore
max distance offshore '
Basin, channel
cubic yards
Boat ramp
Boathouse/ Boadift
Beach
Other
Shoreline Length ,
SAV: not sure yes no —
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
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(Scale:
❑ See note on back regarding River Basin rules.
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Agent or Applicant Printed Name
Permit Officer's Printed Name
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Signature**Please read compliance statement onback ofpermit" Signature /
Application Fee(s) Check# Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: I~ x
Mailing Address: 101Y2 NC %Ywy. 2g,� A-i��, N,,//C ;'7,5s
Phone Number: // 9 —
Email Address:
I certify that I have authorized
Agent t Contractor
to act on my behalf, for the purpose of applying for and obtaining all nC`AMA permits
necessary for the following proposed development: D ��� Imo)
at my property located at
in 0nJ")o-' County.
I furthermore certify that l 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:
Signatures
/fit, ZrJA/
Print or Type Name
Title
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Date
This certification is valid through

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: j
Address of Property:
(Lot or Street #, Street or Road, City & County)
Agent's Name #: _dQSV) Ro y- tx t' FL Mailing Address: ITV 1 rCA j Yl j� Lki
Agent's phone #: 5_it) o - Ci -So (0, (� S �C . I N ( , i PL� (f (i
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing with dimensions must be provided with this letter.
K I have no objections to this proposal. I have objections to this proposal.
If 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. Contact information for DCM offices is
available athttp://vswnr.nccoastalinanagement.net/weblcnl/staff-fisting or by calling 1-888-4RCOAST.
No response is considered tha same as nn nhiacflnn if vn., hwn h.0 nnt:aeN h., n.,.,:a,.N nfi-.,
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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-
4 1 do not wish to waive the 15' setback requirement.
(PropgM Owner Information)
gnats re
Print or Type Name
/o?Yz (\/C ff1�
Mailing Address
0`( end cis e[C il� C
City/State/Zip
j Telepho a Number/E Address
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Dat
(Riparian Property Owner Information)
Signature
Print or Type Nbme
Mailing Address
City/StatelLip
EG"
Telephone Number/Email Address
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Date /-� £
(Revised Aug. 2014)

Tomm Bm-
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■ 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 mailplece,
or on the front if space permits.
t. Article Adtlressed to:
_C'rtcaas ��1 Ne �LW
111111INIIIIIIIIIIIIIIIIIillllllllllIIIII
9590 9403 0208 5146 1319 81
COMPLETE THIS SECTION ON DELIVERY
A. Signature Q 0,13
6. ec'ved by (P nted N C. D e
(,✓,ll�a�.. Ra n
D. Is delivery address dill nt from y_ ❑
If YES, enter deliveryaddress below: ❑
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2.- Article Number (nansterrromsa--.-- 3466 5976
7019 0700 0002
{- , April 2015 PSN 7530-02-000-9053
■ 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
�}.�ytry 11/i�lar%ih 1
� tv/law�
C� � �, //Y ) 17%►
11111111111111111111 IN 11111111111111111111111111
9590 9403 0208 5146 1319 74
7019.0700 0002'3466 5
Ps Form 3811, April 2015 PSN 7530-02-000.9053
�e Type
❑ Priority Mall ExPM88
gnature
gnature Restricted Delivery
❑ Registered Mall-
❑ Registered Mail Restricted
f Mall®
f Mail Restricted Delivery
Delivery
❑ Return RecelPtfor
DeliveMerchandise
on Delivery Restricted Delivery 0 SlgnatureConflrmatlonTM
0 Signature Confrmation
all
.,ail Restricted Delivery
Restricted Delivery
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Domestic Return Receipt
X ❑ Agent
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D. Is delivery address different from Its /7 ❑ Yea'
If YES, enter delivery address below: ❑ No
Service Type
❑ Priority Mail Rxpreea®
❑ Adult Signature
❑ Registered Mall-
❑ Adult Signature Restricted Delivery
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❑ Reglstered Mall Restricted
21�eNfied Mails
Delivery
❑ Cerilfled Mall Restricted Delivery
❑ Return Receipt for
❑ Collect on Delivery
Merchandise
i Delivery Restricted Delivery
D Signature Confirmation^
9 lap
❑ Signature Confirmation
lall Restricted Delivery
Restricted Delivery
T (over$500)
Domestic Return Receipt
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