Blackburn, Chris 77145C

CAMA / ❑ DREDGE & FILL a
GENERAL PERMIT
VNew ❑Modification ❑Complete Reissue El 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
Applicant Name
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Address V
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City
State N(�LI P
Phone # ) E-Mail
Authorized Agent
p�,(n
E' I Ae CP 4--5
Affected ❑ CW ice nq/ _,nA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes /(?n PNA yes O
( I t
cl?�-Pu Al 01 Vh
Age or Applicant ri ted Name
i nature Please read compliance statement on back of permit
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Application Fee(s) Check #
pursuant to
N9 77145 A B G) D
Previous permit #
Date previous permit issued
15A NCAC (/ 7 14,/ 900
Rules attached.
Project Location: County 1=�N 1 0 1AJ
Street Address/ State Road/ Lot #(s) M
Subdivision
City ZIP
Phone # ( ) River Basin
s
Adj. Wtr. Body OLY n an /unkn
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Closest Maj. Wtr. Body S
kA C9()I)bl )
Per mit0 is P ted N
Signa re
3/ /go
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Issuing Dale Vxpira on Date

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1

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
7
Name of Property Owner Requesting Permit: �� �� S (� Ll'lzv
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized C/ t
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: / ti S
I'i
at my property located at ��� ���azc/ ct, 1 G /c. Z
in (�) hS l ro tj County.
I furthermore certify that l 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:
//3 !� CZ 4, K I'--
Signatur
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Print or Type Name
Title
�Id-�5- l do
Date
This certification, is valid through Z l I ---)0
ago
615 40y
RECEIVED
AUG 2 0 2020
DCM-MHD CITY

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: n �-
Address of Property:
4-/h
/ Sd c4c%" (c /C ZOO).
(Lot or Street #, Street or Road, City & County)
? �1 4. J: 1-�
Agent's Name #:
1;1teen,C
�1�1�iling Address: /�' �4,t-.ti
10r•
Agent's phone #:
491(c) 02 4 3- q "KA
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing with dimensions, must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
if you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at http://www.nccoastalmanactement.net/web/cm/staff-listing or by calling 1-8884RCOAST.
No response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, oust
be set back a minimum distance of 15' from my area of riparian access unless waive y 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
Print or Type Name
Mailing Address
City/State/Zip
j/o-Y46
Telephone Number/Email Address
Date
(Riparian Property Owner Information)
Signature
Print or Type Name
Mailing Address
City/StatelZip
Telephone Number/Email Address
Date
(Revised Aug. 2014)

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: cfypl ( r S 0E10%c4ku ✓ s,
Address of Property: �� �h4�w� c�c h . Sh.R�� f-?ii� h `I,C - a�`4�
G o
(Lot or Street #, Street or Road, City & County)
Agent's Name #:.Sdv „�,( S� A'krrt.tic M iling Address: /- 9 (f 0, ha i`VP �r
Agent's phone #: �/ oZ63 4{,( (fx S h� S f, 7 /zG o�(j�yGv
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing, A description or drawing, with dimensions, must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at http://www.nccoastalmanagement.net/web/cm/staff-listing or by calling 1-888-4RCOAST.
No response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, oalift ust
be set back a minimum distance of 15' from my area of riparian access unless waive me. (If
you wish to aive 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)
lq,A- -
ignature
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number / Email Address
Date
(Riparian Property Owner Information)
Ax 4�;. ! �
Signature %
&LN//
Print or Type Name
Mailing Address
City/StatelZip
Telephone Number/Email Address
z/- )2-
Date
(Revised Aug. 2014)