Willis, Sarah 84684C

`AR4,1N❑CAMA ❑ DREDGE & FILL N984684 A B C, D
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GENERAL PERMIT Previous permit
y 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:
I SA NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name
Address
City
Phone # (_ )
Email
Affected ❑ CW
AEC(s): ❑ OEA
ORW: yes/no
Authorized Agent
Project Location (County):
State ZIP Street Address/State Road/Lot #(s)
DEW ❑PTA
❑ IHA ❑ UW
PNA: yes/no
Type of Project/ Activity
Shoreline Length
Access Length
Pier (dock) length
Fixed Platform(s)
Subdivision
City
171 ES ❑ PTS Adj. Wtr. Body
❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
i
(Scal9j,j' )
Floating Platform(s)
Finger pier(s)-
I E
Total Platform area
I I
I � �
Groin length/#
Bulkhead/ Riprap length .-__ �. . ,_ \ ' .. ..- - l G--
Avg distance offshore _ x.
-�_
Breakwater/Sill
Max distance/ length
a
Basin, channel
Cubic yards ( r°
_ I{r
Boat ramp € € A
Boathouse/ Boatlift _
Beach Bulldozing
1
Other
..,._. . E I"-- E
SAV observed: yes no -
Moratorium: n/a yes no �, I
Site Photos: yes no _ _. _ __ u{., - € __._ �� -_ - -- - -- -
t
Riparian Waiver Attached: yes no
A building permit/zoning permit may be required by:a
❑ TAR/PAM/NEUSE/BUFFER (circle one)
Permit Conditions
❑ 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 Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit" Signature
Application Fee(s) Check #/Money Order Issuing Date Expiration Date

oa+F tOASr41 ❑CAMA ❑ DREDGE & FILL N9 84684 A B C D
s = GENERAL PERMIT Previous permit
Date previous permit issued
01EINew ❑ 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 ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name
Address
City State ZIP
Phone # ( )
Email
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
Shoreline Length
Access Length f
Pier(dock)length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Total Platform area
Groin length/#
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/Sill
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing \
Other
SAV observed: yes no , !
Moratorium: n/a yes no
Site Photos: yes
Riparian Waiver Attached: yes no f
A building permit/zoning permit may be required by: l t " `' r j ,' J ^ i y
Permit Conditions f a
;)
0
❑ 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 PROJECT 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" f, Signature
Application Feels) Check #/Money Order Issuing Date
Expiration Date

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I hereby certify that 1 own property adjacent to
property located a
�� (Address, Lot,
on , in
(Waterbody)
cul IG` Is I
r%Fperty Owner)
� �'[W , N.C.
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
� 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)
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. (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.
(Properly Owr)er ingormatigr)) (Adjacent Property Owner Information)
Sign u
Prinlpl�peJ`i/�
Cify/State/Zip�"Llel
13 U 13 761
Telephone Nu be / email address (�
Date
Siznature*
JUN Q 8 202?
Print or Type Name
_ D d v5 Z4s "') > nip'-MHD CITY
0 5-7 Mailing Address
City/State/Zip
be ,Z- "— A- i--
Telephone Number/ email address n
:33-6�- a%
Date* Al e%
(Revised Aug. 2014)
*Valid for one calendar year after signature"