Collie, Vicky 80075C

^ )�CAMA / ❑ DREDGE & FILL 1V 9 80075 A B © D
NERAL PERMIT Previous permit#
ew ❑Modification ❑Complete Reissue [-]Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resourcesi Commission in an area of environmental concern pursuant to 15A NCAC� /
` Rules a ched.
`
Applicant Naame j �iy CAI re- Project Location: County
Address- 3 e Street Address/ State Road/ Lot #(s)
City State zlp
Phone # -Mail Subdivision
Authorized Agent U, f� City ZIP 'A
Affected ElCW W �'A ❑Es ❑PTS Phone# ( ) River Basin Ve
AEC(s): El OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body 1 nat an unkn
❑ PWS: t
ORW: yes �o PNA yes /� Closest Maj. Wtr. Body
Type of Project/ Activity k U CJ
ri 1
(Scale:
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s) �,—' — — -- _--- r
Groin length 1
number
Bulkhead/Riprap length
avg distance offshore
max distance offshore,
Basin, channel Zi
n coy cubic yards_--,�
Boat ramp-
9
Boat
hous(--
r_
Beach Bulldozing
Other
Shoreline Length U (,/
SAV: not sure 4yesno
Moratorium: n/a Photos: Waiver Attached:
A building nermit may be reouired b
Name
��iIJ'fi1&a, hUtjr-f1-! O
y. j K{\O�r ��� Li See note on back regarding River Basin rules. _
S ture **Ple a read compliance statement on backofpermit**
'w� - ►0Uaa
Fee(s) Check#
Sig atu e
Issu— I g at6 �xpiratiltfn Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit V_ j e ky
Mailing Address: .3 (� Arkew y'ita t .D t iy b
Pine Knoll Shores LC Z � 5 ►Z
Phone Number: U 5 i) % 4 5- 0 Z 3 8
Email Address:y i C�y C p l l e v r� ha o ca im
I certify that I have authorized �� 13 4 c �(� t j�2c �.� �,� ` 6� �•
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at H O p J r-b o r \ 1 i -} 4,r2, D r I t €-
County.
1 furthermore certify that 1 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:
��ll �J 1 CUtX l�
Signature
V'i .kv CplGe-
Print or Type Name
�ror�t'.r�v UvJ[1P,�'
Title
5 1Zq1 21-
Date
Fj I aoa-
ClI 1a66a
RECEIVED
This certification is valid through I I JUN 14 2021
DCM-MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacentto_
Property located at ) 3 'A, L� o
(Address,
on �� Yu rQ in-
(Waterbody)
� �lL� ce �}te •<
Name o ��Q�Y Owner)
rCodd, etc.)
5 N.C.
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locption.
1� I have no objection to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(Indrviduaf proposing development must fill in description below or attach a site drawing)
13 -� 0J9
o
• EY, tS-) � Avg Ft`IeCi
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 tto faive the setback, you must initial the appropriate blank below.)
U 5 �I do wish to waive the 1& setback requirement.
I do not wish to waive the 16 setback requirement.
(Property Owner Information)
I ,. �
C
Print or
Fi a e- Knoll bhorz5 NC 22 12-
CZS2p 24 S' O Zs` z
Telephone Number
5-49-2(
Date RECEIVED
JUN 14 2021
(Adjacent Property Owner information)
Signrdure IQ
MA(= i C d
Print or Type Name
l3->— AP,0�Rt� ?^
Mailing Address
PilJe,-%i
'2-7 z --- 2 �v -- 9
Date 0 9 9/ 2 U 4
(Revised 6/l a2012)
DCM-MHD CITY

ADJACENT RIPAIBAN PROPERTY OWNER STA
1 hereby certify that I own property adjacent to 1/ 1 L I L 4'prg4'--
p o
imam of
property located at i C7 A r' L o r^ v i +A Q 'J J ✓ rim
�/� )tip , (Address, Lot. R , etc.)
on _ L . N.C.
(Waterbody) (Cityfitwm andfor Conntyj
The applicant has described to me, as shown below, the development proposed at the above
location_
1 have no objection to this proposal
DESCRIPTION ANDlOR DRAWING OF PROPOSED DEVELOPMENT
(ladfvictua( proposing development must M In descdpfion below or attach a aft dfawla-9)
I3' ---;>
• 4b
13 1 � � �'g I t �k-
I
q, o
FE j a ,4-'te (' f �• r jp i�c3 G�C,
WAIVERSECTION
1 understand that a pier, dodo, mooring pilings, breakwater, boathouse, Ilk or groin must be Set
back a minimum distance of 15 from my area of riparian access unless warred by me_ (if you
wish to waive the setback, you must initial the appropriate blank below.).
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 13 setback requirement
(Property Owner Information)
e
5,i2
vVPZ 2 4 S 0 Z9z
Telephone Number
5—Z9-21
Date RECEIVED
(Adjacent Property Owner Information)
Signature
SCMAm iW 5.LJ (" NAM !1 Dth2 W, w4u.-a---
PrintorType Name '�—
p�/SDS X,riCl�:ll �.-�I,�Q �1riX3rv�ic7E. �i�.
1MAa�Nc Z,k°rc/r KS. Alc aBSIZ
S-2q^tn?-1
Date
(Revised 6H&2012)
JUN 14 2021
DCM-MHD CITY