Atherton, John 77200C

X(CAMA / XDREDGE & FILL �� NO 771- 0 A B 0 D
GENERAL 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 j ,
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NC AC 0!- —9 . A + 0 14, 1100
j ❑ Rules attached.
Applicant Name 7i�1A_ A 'feS—c�bn Project Location: County('­g-ay n
Address 19O J t7IC t Street Address/ State Road/ Lot #(s) �.
City State ZIP
Phone # 4�) r E-Mail. �1 Subdivision
Authorized Agent !y A11 (� t,�lj�./��s City / ZIP
CW �_,�,fW PTA ASS ElPTS Phone # ( ) River Basin at G -
Affected ❑ OEA ❑ El HHF IH UBA N/A y
AEC(s): Adj. Wtr. Body A�o/%ls Vim-G.I�— n�a /man /unkn)
❑ PWS:
�: Closest Maj. Wtr. Body
ORW: yes /p(io) PNA yes n>o
Type of Project/ Activity
Pier (dock) length ..
Fixed Platform(s)
Floating Platform(s) r
Finger pier(s)
Groin length
number
Bulkhe %Rip�ength
avg istance offshore
max distance offshore
Basin, channel
cubic yards_
Boat ramp
Boathouse/ Boatlift
,r
Beach Bulldozing
i
Other
Shoreline Length
SAV: not sure yes no j —
1 -. ;- :_
Moratorium: n/a yes .
T.
Photos: yes , _
Waiver Attached: ye no i .... f ( `
A building permit may be required by: rV0we4 CsS? l /
( Note Local Planning jurisdiction) I
Notes/ Special Conditions. Na Cs: PY rav-a±t
O ( S
ent'or Applicant Printed Name
Si nature ** Please read compliance statement on back of permit
Application Fee(s) Check #
(Scale: :5; r® )
See note on back regarding River Basin rules.
3- I. � ��� -(:�, 6Zl/0KAJ
5tJ .� fI
Permit Officer's Printed ame
Signat re
(� la 7 0P-
ISSUI g Da Expi ation Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to Jomz - - Tgt�5:A kwAvi-
s
(Name of Property Owner)
property located at 662I y/1/a �iT�J u tlCaq s 6
(Address, Lot, Block, Road, etc.)
on MA19 M in N.C.
(Waterbody) (City/Town and/or County)
The applicant has, described to me, as shown below, the development proposed at the above
locatiory
1/ 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)
y-, ailLd i
t
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwatbr, oathouse, lift, or c�
must be set back a minimum distance of 15' from my area of riparian access u aived by
me., (ifyouwish to waive the setback, you must initial the appropriate blank below.)
V I do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement.
(Property Owner Information) ( Ojacent Property Owner Informatig�)
Signature Signa ure * c
Print or Type Name Print or Type Name v
-'�-Vl ytx -Zip, - .- 7&)`�'r,Qv-
Mailing Address Ma' ing Address
ctvC C_
Telephone Number/email address
- 4M - Via) s
Date
713fgi
*Valid for one calendar year after signature*
LV
Telephone Number/email address
`i / 1 / mac,
Date *
(Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ti/�i�{l)i �� �� 's
(Name of Property Owner)
property located at 7� =z6 - t i� �� '/!/ V �1 Ak
(Address, Lot, Block, Road, etc.)
on /--DR15 CK in /Abk , N.C.
(Waterbody) (City/Town and/or County)
The ap licant has described to me, as shown below, the development proposed at the above
locati
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) /
Li C9 P � 1 l� f`t 1p D tU GtJ/`j-G .�G � � &F
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distance of 15' from my area of riparian access unless waived by
me. (I�u wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
U I do not wish to waive the 15' setback requirement.
(Property Owner Information)
(Adjacen perty Owner Information)
Signature
Sig atu e*
u
Print or Type Name
Print of Type Name
M fling Address
Mailing Address .�
/Jf-1
City/State2ip 79-' ) Zq 1Dl�' �l City/State2ip
Tele p one Number/ email address
Telephone Number / email address
t z12b
/3,v .%���7,>
Date I I
Date*'
(Revised Aug. 2014)
*Valid for one calendar year after signature*

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: VW /l
Mailing Address: oe To wy C�
IV
Phone Number:
Email Address:
I certify that I have authorized
Agent /
.//! 41 IL , ".4'1
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
( 'VA[
necessary for the following proposed development: nI P mil° 0/1/ U*12 S:V b
.66E off ! itV 69-AL 2. 7-0 S'IM14) z.E- S HUELI1�%
at my property located at 00 ' &e°-�; . IV
in Cf / VW County.
/ 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:
ri'a4vm,f O%L
Signature
Print or Type Name
,2C
Title
l J /
Date
This certification is valid through .�/ /J 19Y