Burks, Michael 84493C

'o�pFCOASTq� ❑CAMA ❑ DREDGE & FILL 84493 A B C D
y ? GENERAL PERMIT Previous permit
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:
15A NCAC ❑Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name _
Address
City
Phone # ( )
Email
State
ZIP
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
ZIP
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
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 no
Riparian Waiver Attached: yes no
A building permit/zoning permit may be required by:
Permit Conditions
(Scale: )
❑ 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"
Application Fee(s)
Signature
Check #/Money Order Issuing Date
Expiration Date

`p1*pE(AAST41& ❑ CAMA ❑ DREDGE & FILL NO. 84493 A B C D
z =GENERAL PERMIT Previous permit
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:
15A NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: www.degnc.gov/CAMArules
Applicant Name _
Address
City
Phone # ( )
Email
State
ZIP
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
P
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
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 no
Riparian Waiver Attached: yes no
A building permit/zoning permit may be r
Permit Conditions
equired by:
❑ 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" Signature
Application Fee(s) Check #/Money Order Issuing Date
Expiration Date

Name of Property Owner Requesting Permit: ir,, rfCzr
Mailing Address ] i4 ,5. I&I
Phone dumber: t C 30 s
Email Address: C i d � 50 C Ci—nme (- c eij
1 certify that I have authorizedZ ffd Z4 U) J I IC -A J
Agent i Contractor
to act on my behalf, for the purpose of -applying for and obtaining all CAMA permits
necessary for the following proposed development:
-Aj,y A, L
at my property located- at 0�-+r���,�
in f dLL! 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:
Signature
Print or Type Name
Title
�{ -'�"L _
Date
This certification is valid through--i _A_! ,

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QUAG NT-RIPARIAN PROPERTY ®"JVNER STA a EMENT
I hereby certify that I own properiV adjacent to t!RX I, " "--s
- - (Nansie cif Property Owne- )
property located at - 7;C>`
'Address, Lod, Block, Road, etc.)
on In. f12&iI 5�4 &4&k2 U.C.
('.illaterib©dy) (CitvlTown andlor County!
The applicant has described to me, as shown below, the development proposed at the above
locati
1 have no objection to this proposal.
h�v_� objectroa�o ttis pr_opos.al�-____
DESCRiP T ION AND/OR DR -AWING OF PROPOSED DEVE
OPil1rN
O'PdiI,77dUai rroposinig development,-nus? fill In descripft-n below or afiacpe a sf> e dravusr?gj
_ -- - VVA-i`y`ER 8ECTi0IN .
!.understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
.back a minimurn distance of 15' from my area of riparian access unless tuaived by me. (if you
wish to waive the setback, you -ust itial the appropriate blank below.)
i do wish to waive the 15' setback. requirement.
i do not wish to waive the 15' setback requirement
(Propefy Owner Infoena-flion) 4 VC0 ` Pik 8MI Owner Infor.-naVop'
Sib aiur•e Signaiure ��i��y�' --.._
Print or Type Name Print or Type Na e ,
Afla11ing-Address Mailing Address
t✓�� rt �g� , i �' `fix ,
City/State/Z- � a'�k' '� �- s5
Crt;T�S,t�a` te/zip ra p
• .- �., W LO' dJ i °J dam. j
Telephone Number Telephone Number
Dale
Date,
(Revised 61212012)

ANAGEN i RIPARIAN PROPERTV OWNER STA i EMEN k
I hereby certify that I own prop. erty adjaceni to
(Name of Peopee rii Owner)
property located at OAK H 14 ►"fit c> C.- 100--
(Address, Lot, Block, Road, ot6e)
on in. i 5L117y ? N C.
11 ll:aterb©dYi (CtM' Town and/or Counilf"
The applicant has described to me, as shown below, .the development proposed at the above
location.
1 have no objection to this proposal.
hav_z �O-CforLs zo-twis_pco-posal.__._____
DiSSCRJP T IJN ANDIOR DPAWINC Or PROPOSED DEVELOPMENT
(Irldi�rld�aal Pro.00sing deveioprnepi must fill in descilption begow or a�acI-? a site e d►-awlr?O-I
_.w_ ----- VIIA. IE SECT ION
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 r-Pust initial the appropriate blank below.)
I do wish to waive the 15' setback
I do Foot wish to waive the 15' setbaclyfq'uirement
Sibnat r•e
Print or Type Name
Mailing -Address -
22E V- J' >i
City/State(Zip
Telephone Number
Date
'k-Ad9acent ProPer�jf Uwr�eLI Informs ion)
Sian �i .re.
PrjntoT ype Name
ii "da ,y.�T—>- .
I&N.36
ss
91
, fmp*
t o
Telep one ►umber
Date De
(Revised 6111812012)