Henry, Harry Jr. 76606C

�(CAMA / KDREDGE & FILL
GENERAL PERMIT Previous permit #
ANew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality J, r�^^
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC f-7 �(� 1yV + 0 7
I,t<rRules attach
A licant Name h 'C"r V P-n I Ny . CB Project Location: County
pp
Address
City_❑
r
Phone # G�o
Authorized Agent
Affected ❑ CW
AEC(s): ❑ OEA
❑ PWS:
StateAr— ZIP_
E-Mail
❑ PTA A%t ❑ PTS
❑ HHF ❑ IH ❑ UBA ❑ N/A
ORW: yes /t°no PNA yes
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
nrTiber
t!u a /'Riprap length
avg distance offshore_
--max distance offshore
Basin. dhannel„ L(! /' yr,!' n o
cubic yards _i C
Boat ramp r
Boathouse/ Boatlift r
Beach Bulldozing
Other
Shoreline Length 70
SAV: not sure yes no
Moratorium: n/a yes n
Waiver Attached: /vei no
A building permit may be required by: 1OXA�
( Note Local Planning Jurisdictio ))
Notes/ Special Conditions
--- Aa�n/
ge r.App a Printed Na e
Signature "Please
ase read compliance statement on back of permit"
M? C)
Application Fee(s) Check #
a
Street Address/ State Road/ Lot #(s)
Subdivision
B (." D
991, i�
City '0 `. ZIP
Phone # () River Basin
Adj. Wtr. Body nat man unkn
Closest Maj. Wtr. Body
(Scale:
❑ See note on back regarding River Basin rules.
fin ,s11,nt1l n®I (nAntO?+fna
PermitOfficer's Printed Na
Signatu e
Issui g Dat pirat' n Date

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit:
Mailing address: C �/ �'�1✓
�s- /V L�5 �G
Telephone Number:`Jca�_
I certify that I have authorized &99,Y L 1L0 9
CAAy(agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of S'��
at my property located at��
This certification is valid through Q—UML 30 � wo fqb (date).
(Property Owner Information)
V// Ae��
Signature
4. - & iG
Print or ype Name
< r � 1USd 61-/4-no �Jii � .- �/Z �vT7
Title, co. owner or trustee for property
O O
Date
�) 73a - �13 60
Telephone Number
M A9/%.0- k/ E C r I` y coOf
Email Address

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT/
I hereby certify that I own property adjacent to/'%�/�/����1<<��`���t y Is
, Name of Property Owner)
property located at G 91 S� err
(Address, Lot, Block, Road, etc.)
on rA 6 !/ � � in �/l/l- N.C.
(Waterbody) (City/Town and/or County)
The a licant has described to me, as shown below, the development proposed at the above
locatio
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
o�/�/'�.fJ/�/?�
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.
Information
Print or Type Name
Mailing Address
City/State/Zip
';2 5 �2-'2 y/ -io9Y
Telephone Number
Dale
Property Owner Information)
Wl�- Q'�w` �iiP�t_Dr Nam,
Print or Type Name
Mailing Address
City/State/Zip
r
Telephone Number
Dale
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 7fiooy'-7i , ,ti C126�- /r -- s
(Name of Property Owner)
property located at �,(f -��-� ����
(Address, Lot, Block Road, etc.)
on b�- �i in /Uv, N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loon ion.
c). I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
"i b/25,e7 G2:t/�= �� �/ �� 7Z
S� S611 6117/-75- /1/7'�' (, (:�
11
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.)
it I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
perty Owner Information) (Adjacent Property Owner Information)
Prnt or Type Name
�/�/
Mailing Address
/UC.'
City/State/Zip
S�-.,2�/-/09.
Telephone Number
'V'-1'3- A -2<-)
Date
Q�irft or Type Name '
Mailin dress
L (
City/State/Zip
N e, \;Q po r N C, a � s -70
Telephone Number
Asa-�a3-�
Date L_ 1-]- 2-02- D
(Revised 611812012)