Qualman, Roger 78857C

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QIENEIAAL PE11MIT
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)OAMA / ❑ DREDGE & FILL N9 78857 A B O D
E�NERAL 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 % �,,y,��
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC /�"L�/
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Rules a shed.
Applicant NName(F, Q 1 1(� lj n (/� f� Project Location: County e
Address 5A ) � J , . Kw- Street Address/ State Road/ Lot #(s)
City
Authorized Agent
Affected —ArcW A [I ES ❑PTS
AEC(s): ❑OEA ❑HHF ❑IH ❑UBA ❑N/A
❑ PWS:
ORW: yes'/ n6) PNA % yei)/ no
Type of Project/ Activity
Subdivision 03prey
City ZIP
Phone # River Basin S
Adj. Wtr. Body t dk a ian unkn
Closest Maj. Wtr. Body
Pier (dock)length
Fixed Platforms)
Floating Platform(s)
Finger pier(s) •�
Groin length
number ✓
Bulkhead/ Riprap length—
avg distance offshore �
max distance offshore` J
Basin, channel
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Signature **Pf�se read compliance statement on back of permit"
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4lication Fee(s) Check#
Permit
Date

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RECEIVED
FEB 17 2021
DCM-MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to )�?n > > r al w, r� n I
gName of Property Owner)
property located at S ti t Qso r•ey f'D� ni Koacl
(Address, Lot, Block, Road, etc.)
on �aCFC L° rec I< in (3 e iu +o; -t- , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
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)
/kCK- i✓t �K �1,,
I. j .Sun DE.L K- 'I'O
•5.
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t' ci r�uG o�
Zip r--C K
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.
Print or Type Name �n
5+-1 l CU SnP�.i �� ,i Load
Mailing Address
n ua ',) + / )\) C /.2 X514�
City/State/Zip
5tµ3 -a�� - 7�i55�ro�e rguajwan f�yai.uc <<'+^
Telephone Number/ eftiail address
11 l7
Date
(Adjapgnt Prro erty wner Information)
Signu
r-
- 0 5-2 2ts 21 2 z
Telephone Number/email address
� /Jov - 9 2oyo
Dare
i
"Valid for one calendar year after signature'
(Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Q "CA w, a., I
(Name of Property Owner)
property located at 5 y Uspce.t PDi rd (Z0�41
(Address, Lot, Block, Road, etc.)
on %Q L k. Creek in 93 QC1 _}- N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
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)
i
_v_ j2D�Cd Ca,`
II 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.
( er Information)
i
Signature
Print or`Type Name //
5 ti i D so re_.r Po i i Koarl
Mail{l{�tg Ad ess
1Seaa r� tic �ZY51�
City/state2ip
143 -,7,2y' 711 S5 � Lo ra ua ,
Telephone Number/emat ad ess
i� / � � Zozo
Date / '
(Ad' cent Property Owner Information)
c1yJ7.liii�_% 1� A i
Si ature*
el I-,
Print or Type Name
100 (;, rretoym- 1 f?O1.
Mailing Address
Llha�l All, , We- 2-1151'7
City/stat /Zip
919-&(o'7-J7414J'1�3rrcuv)l,.@'Clotcol. com
Telephone Number/email address
11 /7'2O,Z`,O
Date* 1�
*Valid for one calendar year after signature*
(Revised Aug. 2014)