Larson, Vincent 78870C

CAMA / @DREDGE & FILL C/ NO %gg%Q A B (D GENERAL PERMIT 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� 7 // /.•� ')0")
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC 0�.. l i 6�(;/ 4- in / 17` d (gor .
Rules attached.
Applicant Naanme p SO f Project Location: County aK4&3�&
Address d Street Address/ State Road/ Lot #(s) 532QA ftf/
Ciry &�
State ZIP
Phone # ( ) E-Mail t- Subdivision
Authorized Agent ff RtLr L'I NeAq/IIiJ/lam City ZIP
Affected �CW aeW �¢�PFA �es ❑PTS Phone# (_) PoverBasin
AEC(s): 0EA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body (nat an nkn
❑ PWS: �,�� �
ORW: yes no PNA yes no Closest Maj. Wtr. Body--3f� s
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s) �
Floating Platform(s) lIG JZ
Finger pier(s)
Groin length
n ber
Ikhead/ rap length
avg distance offshore
max distance offshore
Basin, channel
r
cubic yards
Boat ramp
Boathouse/ Boatlift r
Beach Bulldozing
a
Other
f%
Shoreline Length 7 lJ i I ITTIVA i 1
SAV: not sure yes o -
-i
Moratorium: n/a yes no
Photos:Waiver Attached: esl n -
A building permit maybe required by: t l tQLo� d\C 7
( Note LocalPlanning Jurisdictionp , _tLe
Noes/ Special
ecial Conditions �C1�1 6A1 IlY1! � �3h Q I r
or Applicant Printed Name `
+sign re **P a read compliance statement on back of peermmiit**
_ l A 10,
Application Fee(s) Check #
❑ See note on back regarding River Basin rules.

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: V f hJ Glr /U T L- SyNr
Mailing Address: 1 29 P D/e
Phone Number: a.sc�7, �2,'9 % - J / 0 7
Email Address: eO
c
I certify that I have authorized t10 0 rZ a e- K E 1 72 g f7��J � 4 t'�✓� � 4
6!�oA.)-G 1)67/DA.9entIContractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: l2t P LAcEr(aIr7 0 e=xIS7-
i
/�o�r7 i�i[aLKNEK# A.vn ADi)11UC2; A
at my property located at l Zgi BEE -( NW wo o o oje P/< S
in Ct127 r72Ei 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:
Signature
V ldc-ex) L APe sold �,---
Print or Type Name
Title
f l 16 1 `Z / MAR 0 4 2021
Date
0CM44Hp C11'Y
This certification is valid through I I

I hereby certify that I own property adjacent to _
property located at L vi 6
(Address,
on , L Ail)) L in _
(Waterbody)
The applicant has described to me, as shown b
location
I have no objection to this proposa
DESCRIPTION AND/OR DRAWING i
(Individual proposing development must rill in
rL0Ai /A)4� boe--,-.
f
(Name
Block, Road, etc.)
ti ,P-S oti s
Owner)
S N.C.
own and/or County)
the development proposed at the above
PROPOSED DEVELOPMENT
scription below or attach a site drawing)
i tJG� A eD
4"On /A{roN?ot.�>91iIi'511
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 ol 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' setba k requirement.
(Property Owner Information)
Signature
✓i�7Gcro;� L�2So,c�
Print or Type No
/z 9 �c66Htdoab D�/cJc
Mailing Address
P11'11c 1-</V4,1,
City/state/Zip
52- --. 47-3/ S 7
Telephone Number
Date
(Adjacent Pr p rty wnerInformation)
SigngMre
M-40J2L Gl�l'✓�✓
Print or Type Name
l3/ &S (,dam DR
Maili , Sddress
City/state2'p
Telephone Number
/ -3/ - z/
(Revised 611812012)

I hereby certify that I own property adjacent to
property located at
(Address,
on in _
(Waterbody)
The applicant has described to me, as shown
locatiop.
_'b'^•�",d}- I have no objection to this propo
NL�c> LA2So� 's
/Name of Property Owner)
,0/✓E5
ock, Road, etc.)
SfJo/G N.C.
(City/Town and/or County)
the development proposed at the above
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in description below or attach a site drawing)
2z= foLACEM�,v-T O>✓ �X l ST<.c.J� GJvc�C�
�LDA7/.U6j T,OLI<
p
�lo6�ln5'Q GC
WAIVERS CTION
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 oi 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' setba k requirement.
(Property Owner Information)
Signature
Print or Type Name
l Z `I
Mailing Address
J'� k'iIIOLG SflO 2�S A,)d
City/State/Zip y8 s'r Z
-_3 /S 7
Telephone Number
1017T
(Adjacent Property Owner Information)
stq� s
N
Print or
City/Stat*,, 4 r6, 4726
Telephone Number
Date
(Revised 611812012)