Smith, Allen 76764C

KCAMA / ❑ DREDGE & FILL
qENERAL 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 /r� �y��
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC . !'vr
AA �-% / Rules attached.
Annlirnnr Nam-/� 1 e iP_/1 M 1 l L'1 Proiect Location: County r
Address U /Jo I h r� �iyl�liCi Street Address/ State Road/ Lot #(s)
City11N In�rll c ate C ZIP9'651o2-
Phone # () "'
jE-rMail
Authorized Agent ���
Affected ❑ CW AfW PTA
AEC(s): ElOEA ❑ HHF ElIH
❑ PWS:
❑ ES ❑ PTS
❑ UBA ElN/A
ORW: yes /'noPNA yes /
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
number /
Bulkhead/ Riprap length
avg distance offshore,
max distance offshore
Basin, channel
cubic yards
Boat ramp
Rnathmmat Rn
Beach Bulldozing
Other
f
Shoreline Length
SAV: not sure yes 4aQ.
Moratorium: n/a yes no\
Waiver Attached: yes 1 no
A building permit may be requi
Subdivision
City ZIP
Phone # () River Basin
Adj. Wtr. Body 14
✓ nat m /unkn
Closest Maj. Wtr. Body dsol
/ ® /
(Scale:
red by: r ralo j i 0 It ��1� � ❑ See note on back regarding River Basin rules.
Age t or Applicant Printed Name Permit Officer's Panted N
Signature**,Neaseread compliance statement onback opermit" Signat�
Application Fee(s) Check# Issuin bat xpira on Date

AGENT AUTHORIZATION FOR CAMA PERMIT. APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number: 5;-) "7.23- -)pqI
Email Address:
I certify that I have authorized
Agent/Cant ctor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:i
at my property located at 11 5;- 12 "
inCounty.
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-retated to this
permit application.
Property Owner Information:
11 �� )f ���
ig 'na FL re
�tj
Title
Date RECEIVED
OR 21 ZO
This certification is valid through I I DCNI_N►HD C"TY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to. �� 5Tn S
(Name of Property Owner)
property located at L aI-f3 -T
(Address, Lot, Block, Road, etc.)
on J�nf � C-A P-h in J IDS C.PrVr-e`f*r N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
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)
C.ArJX-N L-
Q�,v
���rr D�
VWAIVER 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.
do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjagept Propeerty/ Owner Information)
Signat re
Print or Type Name
B I Sr t.J q LPJ-I
Mailing Address
Pe-5 _
C /State/Zip
Telephdne Number
- F7 - --2 112 b
r..
y115 V�
ling Addre s
SL — ;2 li {— b 57�
h neINtmber
3 .3 � 2143 RECEIVED
Date
(Revised 6/,0/90t) 2020

av* / ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
i hereby certify that I own property adjacent to �Cscn'� 's
(Name of Proper Ly Olmper).
property located at%
° x d (Address, kot, Block, Road, etc.)
on L- in Vl(A- - _ 1 -a_,t i.
lam` (Waterbody) (City/Tovv� nnaand/6r County)
,a 6 The applicant has described to me, as shown below, the development proposed at the above
locati n.
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~P—
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 crust initial the appropriate blank below.)
i do wish to waive the 15' setback requirement.
do not wish to waive the 15' setback requirement.
Owner Information) (Adjacent Property Owner Information)
Sign Lure p—
Print or Type Name
Mailing_ Address
Al iW 21.tm
�asA�j -7a— �� 1
lephone umber
Date
t ( ,'V
MI, ing ,Address
V4hpfiO' umber
&
(Revised 611812012)
RECEIVED
APR 2 X ZON
Cad-MHU CITY