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HomeMy WebLinkAboutGardner, ChrisNCAMA / ❑ DREDGE & FILL GENERAL PERMIT 4New ❑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 Applicant Name i Address City 1 1"i a/ f : .'I iState M ZIP / CXl Phone # (fir ),, (i (c' �'(� / E-Mail Authorized Agent 1 Affected ' ❑ Cw IN] EW ,rat PTA ,C4 S ❑ PTS AEC(s): ❑ OEA O HHF ❑ IH ❑ UBA ❑ N/A L l PwS: ORW: yes / no PNA yes /P N9 78957 Previous permit #_ Date previous permit Project Location: County --- Street Address/ State Road/ Lot #(s) Subdivision A B C D ( �/ h City�� � I I"IF` in IrAc k IP Phone # O River Basin r Adj. Wtr. Body -- 1 nat/ man unkn Closest Maj. Wtr. Body "+ 1 /r/Y{ " r Ore ') - 1 I' f ihm A■■■■■■■■i iiM SINCE MIN ■■■■■E ■■■Oa.■■■. E■■ ■■O ■ .. C....® ■■■ ■■■■� ■ ■■. NINE.. MEW ME ■■NI =■■■■■� .ENI■■■■■■'J ...� ■NI■R! . ■■■■■NEE ■■mom ■■■■■m■■n■■■1 ■■ice/ ■■ NONE ■■■■NI NONE:::{ ::�``:::EN ::OEM dOO■■E■■NII ■E■I■ME :::: I ME:::■NII" M. I ■■■1■■■■■■IY ■■■■skis ■■■■ a Ml 0 MN MM 110 MEN 1111.■.■■■::m::::■ =1 Mom. aE ■ Z E■!E�!1■�■■ A■HEM:NI■mom E ■■■ ■■u ■O■ONE ■■ ■�1■■■ ■®!1■■!INI■■1■ �!■■ESE �■■■■ Olt■NI l�IME IN so iA F`� :: : BNI��E:::: of ■iIUJ::: ,t 41 6A � (Agent orApplicant Printed Name / Siatur's'Pease read com liakE /l� "' Application Fee(s) on back of permit" Check# AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION Name of Property Owner Requesting Permit: C htV) S Ctrr YWC Mailing Address: 10!5 C m-emcn-' Cf. . Phone Number: Email Address: I certify that I have authorized 252 -af9i�- 4667 (-'- G-C(50Csp Msnt, c6M to act on my behalf, for the purpose of applying for and obtaining all CAMA permits necessary for the following proposed development:�1xxa liC at my property located at in County. 1 furthermore certify that I 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: k /� _- Signature l_YtMS Gr1�Waaf Print or Type Name Title Date This certification is valid through VIECEIVED MAR 0 2 N'6 DCM-MHD CITY ADJACENT RIPARIAN PROPERTY OWNER STATEMEN n)1T I hereby certify that I own property adjacent to LS Gs rJne Y- 's �^ ��77 (Name of Property Owner) property located at EEO S1l rs '1 i �0. 1/y'�� C -� (Addres ot, Block, Road, etc.) on BM& �U� -,In �i We. KyNol �hc�teS , N.C. (Waterbody) (City/Town and/or County) The applic nt 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) Q S 66u,r\ Ur\ Nf eke, 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' —_ I do not wish to waive the (Property Owner Information) Signature G.�iz.is Gw+�-o.Jsz Print or Type Name /of CLA7� 0"0+ rT Cl-. setback requirement. 15' setback requirement. Information) Mailing Address M 7ing Address Re'lei 1-4"'JT4- A/c- zaso Y tVC, a7fu15 CityCity/Sta�� City/State ip y/ y aq/ 61 Telephone Number /e ail address Teleph�'e Nuymber/email address // �7 Date �Qrr2(sac1CO5 secur"d�/ r� l RECEM96 G (Revised Aug. 2014) *Valid for one calendar year after signature* MAR b 2 2020 DCM-MHD CITY ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I hereby certify that I own property adjacent to t-kt^13 C—,yA I ek- 's t� (Name of Property Owner) property located at 55D tig- ee5 S1 &q2 (Address, rot, Block, Road, on DCAV2 N.C. (Waterbody) (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) r .x4t utc�.cl!�-� � a ,l�c�Cwa pk I ea�i /0,�ct�tr m P-/)4d fig# a/J4'J�Lf/�'I r!11 m#raMchad 6*14� 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. (Property Owner Information) (Adjacent Property Owner Information) Signature LNR�S &AV-PWCA— Print or Type Name o f c-""&- Po aa7- e-l-. Mailing Address Re CJCY Mo" ., N(L- 7-16o Y CityCity/3ta p z0-1-96-Ll G e•e/T t4SW-e4ti Telephone Number/e ail address Date *Valid for one calendar year after signature* Signature * AN9P-U0 C, 3 Vns Print or Type Name lob R-vroy2A'Pr, Mailing Address , cs,&�>, BAN j ry r✓ a 75) 7 City/State2ip Telephone Number/email address Date* RECEIVED (Revised Aug. 011442 2020 DCm.MHD CITY t•, `fir# r _ w rtrw •� S�i t � , 1 `r 1 cr v 0 1 -n a Q LO a co s p •. I Y ■ Complete Items 1, 2, and 3. ■ Print your name and address on the reverse so that we can return the card to you. ■ Attach this card to the back of the final piece, or on the front if space permits. 1. Ankle Addressed to: ` D.Is MP C�narleS `�O rNc\SD?J If ❑ Agent from Item 17 u re: 69 below: ❑ No MAR 0-2 0/' 3. ❑ Priority Mail Express® IIIIIIIII IIII IIIIII IIIII IIII IIIIIIIII III III III Adult Signaturerly�O ❑ Adult Signature ❑ Adult Signature Restricted Delivery ❑ Registered Malt" ❑ RRegisery d Mail Restdcled 9402 5603 9274 5326 79 [3 Certified Mall® ❑ Certified Mail Restricted Delivery Deli9590 ❑ Return Receipt for El Collect on Delivery - " i Delivery Restricted Delivery Merchandise ❑ Signature ConFlrmatlon- _ - 7 019 014 0 0 0 01 0230 3 0 7 4 tail 4 5 ail Restrioed Delivery ❑ Signature Confirmation Restricted Delivery PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receipt ■ Complete Ilbms 1, 2, and 3. rD.I, - �1 p ❑ Agent ■ Print your name and address on the reverse q ❑ Addressee so that we can return the card to you. ei red by (Pr ted Name) C. too Delivery ■ Attach this card to the back of the mailpiece, , Y - 2�� ,tpr on the front if space permits. r`Yh� item 17 ❑ Yos 1. Icle Addressed to: eliveryES, ent� elow: ❑ No 12: /�ndre� �rhs 0 Ebx-O�v MAR 0 2 2020 b17 6-1U-uwnrd1y.- 3. PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receipt