84623C - Brinson, Donnie

❑DREDGE & FILL NO 84623 A B C D
GENERAL PERMIT Previous permit
t Date previous permit issued
❑New ❑Modification []Complete Reissue ❑ Partial Reissue
As authorized by the State of North CaroliAna, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
15ANCAC 'r tJ�P' ❑Rules attached. V]'General Permit Rules available at the following link: wvvw.deq.nc.gov/CAMArules
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City State zip
Phone#Or
Email
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AEC(s): ❑ OEA
ORW: ves/no
❑EW ❑PTA
❑IHA ❑UW
PNA: yes/ t(o )
Type of Project/ Activity
Nis ❑ PTs
❑SPIMA ❑PWS
Authorized Agent
Project Location (County):
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Subdivision
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Permit Conditions ( , a \;LT't t do y:> , � e7o f h 1
See note on back regarding River Basin rules
See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
Agent or Applicant PRINTED Name
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Signature**Pleasereaq compliance statement on back of permit** f
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Application Fees) Check #/Money Order
Permit Officer's PRINTED Name
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��`°"l%nCAMA ❑ DREDGE & FILL N9 84623 A B C D
Previous permit
�; GENERAL PERMIT Date previous permit issued
New []Modification ❑ Complete Reissue []Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
15A NCAC I ( ❑ Rules attached. ❑ General Permit Rules available at the following link: wwwdeq.nc.gov/CAMArules
Applicant Name
Address
City State - ZIP
Phone # (_ )
Email
Affected ❑CW ❑EW ❑PTA ❑ES ❑PTS
AEC(s): ❑OEA ❑IHA ❑UW ❑SPIMA ❑PWS
ORIN: yes/no PNA: yes/no
Type of Project/ Activity ? ' [' i 1 i'I I \ /
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Authorized Agent
r..
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Adj. Wtr. Body
Closest Maj. Wtr. Body
Pier (dock) length
Fixed Platform(s).
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A building permit/zoning permit may be required by:
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECr AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature **Please read compliance statement on back of permit" Signatur
Application Feels) Check iJ/Money Order Issui g Date E.

AGENT AUTHORIZATION FOR CAMA PERMIT.APPLICATION
Name of Property Owner Requesting Permit: to N"')WE
Mailing Address:
C 94530
Phone Number:
Email Address:
I certify that I have authorized
to act on my behalf, for the purpose of applying for and obtaining all //CAMA permits
necessary for the following proposed development: �� Q 6� SP 4 WC,
at my property located at
in OaA- eA^ e., County.
1 furthermore certify that] 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
D L-V�3 2�
— l l ^ Tifle
Date
This certification is valid through _12- 1-31 1 Z Z

ADJACENT RIPARIAN PRQPERW OMER STA71 EMENw
I hereby certify that I own property adjacent to "D®I%rJ! 2 y(n) S v,J s
property located at d (a �r %9 t- �„� a �% &C isss
w
tttt f?ddr d5, ?, 11oc4, R CI_ iG )
on ,/lf�S V2tiaw'Tf��e�w in y, pz N.C.
(ICRVI T o u andlor CourAIA
The applicant has described to tie, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
DE Od'<_IP T ION ANDIOR DI AUtriNv OF i-NROPOSED DEVE'a9?Mc'.W
11"n�'7 iri�l s';�l ,,roped-?cv Vevelep-Menc mus8 fill In deseripflor below
At t,J
�Jrlt.�sOr, Pr- art-e-r ✓o�Ile,
i understand that a P. dock, mooring pilings, brea{nNafer, 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
!Nish to umaive the setback, you must !Mlal the appropriate blank below.)
1 do wish to waive the 15' setback requirement.
I de. not Nish to waive the 15' setback requirement.
•`fir o e 4f Owner WormS2i0M
a. cent Pr�opye-ri—r :.,mrrrer srsr"ors?�Gaa©r:3
Srnarar, e, Signature-
Do.l iu e �f r„dso rS ��^,o Uis �f.-� li,� �•od
Print or
Trpe Name N Pr.ai or Type NWne
VR}/ JId LC/LI(J
Telephone Number
- Dare -2 1_s:P1.'l c�
zoo/{im s K
iuiailin lldUress
<iak,AIC.2-7Gm
City/State�
9 19 6'2z cf3 E
1 elephone Number
Date
(M. (Pe iced 611812012)

V
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
thereby certify that I own property adjacent to - a tJdl t C �V r ,2 saw) -'s
- � (Nar,1a �� arcl;erty Ownar)
property located at �_ cv �rr qr w . r7 it/C 1853
�1 (,Address, i, lock , d, tc )
on G�'�k�ater Ua�r in_ N,C.
(VUat®ruo®Pt4©dy�j (Cltyflcilvh andlos County)
The applicant has describe_ d to me, as shown below,.the development proposed at the above
location.
I have no objection to this proposal.
DE5C iFMON AND/OR DRAWING OF PROPOSED DEVELOPp7ENT
naiv?dualoroposingdeueiopmen2must fill in.description
halow nasite d_uingj
0 r� voseo���`u' I�
hex a 2�
-.. -—_—._-- .. .. WAIVER SECTION
1 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.)
do wish to waive the 15' setback requirement
I do not wish to waive the 1S setback requirement.
r(P,ropar II Ownor information) - `c-A -- ent Proper
Dote 11)IICE pi��Ury�r7W � ///? V.?© fynw,0-4.,.
- / (Revised 6/1 M0 ii 2)

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