O'Neill, Evelyn 78868C

®IXCAMA / I (DREDGE & FILL $G N° 78868 A B O D
GENERAL PERMIT Previous permit#
XNew ❑Modification [-)Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality EIs
and theCoastal Resources Commission in an area of environmental concern pursuant to 15A NCAC e jjpp��attched.Applicant Name\IVn V�LIProject Location: County e,
Phone #
Authorized Agent /V(u(J( 15LL
ffected ❑ CW AM -PTA
A
Affecte ❑ OEA ❑ HHF ❑ IH
❑ PWS:
IP, {) 6yp Street Address/ State Road/ Lot #(s)
hate !rc'zlp�=
Iil Subdivision
C, City zip
❑ES ❑PTs Phone # O - River Basin r
❑ UBA ❑ N/A 1/ nat unkn
Adj. Wtr. Body ,rnL��/�
! 1 • M_: %A/,.. Q.J.. r l`3eq I I P- S 0 Lt. )
**PI ase read compliance statement on backof
1A
Fee(s)
F W
PermitOffcer'a int d Nam
$ignatu e � AZ
Issui gD to rxpirlfion Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: E"t& 1�,n Vet'-1 1
Mailing Address: )1 (,o R 21oK-v: f,a, 'Dr t v �F-
'F► n-e_ KVIM 11I 2Z� ) 2-
Phone Number: 25'Z Zc{Oci"lQ
Email Address:
I certify that I have authorized
L-s t--I(rt
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: I )y (TA �'e— I ivy k
at my property located at 1 1 6 Bde6-%-et }ae 12c i vc P10 ,N'[.ZT-5I�—
in eCounty.
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 related to this
permit application.
Property Owner Information:
Signature
-
Print or Type Name
pw A,-er RECEIVED
Title
t o 127 1 20 MAR 0 4 2021
Date ')OM-MHD CITY
This certification is valid through I I

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to `� I ✓� ou G: ( l
property located at
(Na a of Property
t7 o i11`� ( :')- i; ) If,i V-
's
(Address, Lqt Block, Road, etc.)
on in I- i ism JLvyo k� 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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
c'l�ehnvl 5`
cr
O
�XIS{�WS 1�bC��
o
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
E yy
Print or T pe Name I _
M ' in Addres
Cfi /Statelzip
Telephone Number
1 o- 2'i• ZO
Date
(Adjacent Property Owner Information)
tA'A � --4� l�
ruff -de Do-
City/SZe" �Z - �p ZZ_ 4113
Telephone Number
(-7— 7—o 6
Date RECEIVED
(Revised 6/1MA0? 012)4 021
0 '- - MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to E " I �J h ®ia t' 1 11 's
properly located at lr 1 1//��
b f (Nang of Property Owner)
�ba►z�o1 �E I
I (Address, Lot -Block, Road, etc.)
on ®w'G in 1 t^_- ICryo lI <� 10-iorS5 N.C.
(Waterbody) (City/rown 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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
� � 11aNae( S
O 412Z 4
b- Z
m �
�x1`Si �wg I-rbr��
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
e Print Type Name
me
v1¢t Drtvs. �O�,� L„&CrzRx>:.� ir91)
Tra nI{,ddcess
Cit�[statemp
D 6 �iC1�6 9 C�i S<
r Telephone Number
:O Z :-:a5 .- RECEIVED
Date
(Revised U1wft 0 4 209'
DCM-Mk?': CITY