HomeMy WebLinkAbout74865D - ThackerJ?L-NCAMA / El DREDGE & FILL NO. %4865 A B C
GENERAL PERMIT Previous permit#
AN2w Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
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
p �� / Rules attac
Applicant Name Th(A `" �V 1 - Project Location: County j tl jm xe/
Address , (7 UL J N 6� S S a V Street Address/ State Road/ Lot #(s)
City State_ ZIP�/S`�2M C)
Phone #11V—/Q)�IZ'Z?j70 E-%Mail
Authorized Agent T i ( 'i 14
Affected ❑ Cw `I W )kPTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
ORW: yes no , j PNA ye no
f
Type of Project/ Activity 5
Pier (
Fixec
Float
Finge
Groii
Bulk[
Basin
Boat
Boatl
Beac
Othe
Shor
SAV,
Mon
Phot
Waiv
Subdivi 'on
City ZIP Zg
Phone # ( River Basin �V • O
Adj. Wtr. Body S at an unkn
Closest Maj. Wtr. Body O UNQO
V
(Scale: 3 e, )
�
■■■■■■■■EEO■■■■■■■E�r■■■■■■■■
■■■l�lr;�■
ng Platform(s)
■■■■■■■■■■■■■■■■■■■�
1■1■■■■■■■■■■■■■�;ffi\\
r pier(s)
■■■■■■■■■■■■■■■■■■■1®�■■■■■■■■■®■■■
VIiJ■�
� length
■■■E■■■■■E■■■■■■■■■!�■!�J■■■■■■■■■■■■■■■■■
number
length
MEMO
No
■■■■■■■■■■■�■■■■■■■■■■■■■■■■■
I - offshore
■MEMME■■■OEM■lrl��■■■■
■■�1/.1■■■■EEO■■■■■■■
J-fe
.,Ice offshore
EEO■■■EEE■■■EiIE■■■■■■�■E■■EE■■■■E■■E■■■
cubic yards
■■■EE■E■OE■■■■■■■■■
■■■■■■■■■■O■■■■■■■
ramp
■■■■■■E■�■OEM■■■■■■E■■■■■■■■■■OE■■■■■■
■■■■■■1!_�c+Rio_,E':�:�■�uir■iw®i■■■■■■!■'■�■
Bulldozing
E■■
MEMO
HE
■I
�i'J■
■■�■
�!■CIE■■■��■■■■■■
fline Length
not sure yes
■■■■■■■■EI
I�JlICE■E■Y■■■■■■■ili■�Il�i■!■E■E■■■
FS: yes
OEM
No
�-
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
orf
Signature ** Please reacl6mpliance statement on back of permit
Application Fee(s) Check #
❑ See note on back regarding River Basin rules.
Printed Name
(/Z.- I � • 2 0 � , q76
Issuing Date Expiration Date
AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:v L4kejr dry
Mailing Address: , //, f
Phone Number:
Email Address: ----��
I certify that I have authorized UGC/"! �ti� �� ,
Agent ! Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at _QL
in County.
I 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:
Title
l/7
Date
This certification is valid through ZZ / '3/ 1 A�Vo
ADJACENT RIPARIAN PROPERTY OWNER- STATEMENT
I hereby certify that I own property ad'acent to % /`1 [� �y . is
(Name of Property Owner)
property locc�at`ed at S
on C ?/ (Address, Lo Block, oad, .)
in 71 f , C� �f�� N.C.
(Waterbody) / (ChylTown 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, 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)
01
Si a ur�-�-----�-
o
PH t or Type amp
Mai ' Addre
City/Sta %Zip
Telephone Number E� D
ri .
(Adjacent Property Owner Information)
Signature
Print or Type Name
� � 1 Ise n ►-,,�d� �cl •
Mailing Address l 1
C4VStateOp
'olI C) 7 yoy 7
Telephone Nu ber
Date
(Revised 6/182012)
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to b,V� Kc�� .,s
property dZi i �J (Name of Property Owner)
located at lJ / 575 l r
(Address, Lot, I ck, Roa , et )
on Gt/ , in - , N.C.
(Waterbody) ityrown 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, 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)
Mi{in, ddrMess /J
Crty�ip &-�
Telephone Number
,?-/3--;0"71)
Date
(Adjacent Property Owner Information)
lzf�e-�
Signature
i1116&4 L. Gc-, ,Ocrc�G.ZSI S.f'
Print or Type Name
ai//ing Address
QV State/Zip
`7/'0-5- /z-5 ?y/
Telephone Num er
��y/2ozv
Date
(Revised 6/1WO12)
AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address. -
Phone Number:
Email Address:
I certify that I have authorized
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
rt
County.
I 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:
Signature
Print or Type Name
Title
1
Date
This certification is valid through /
���5
Data Rac~
Data
Check Flom
Name or P—W Noklar
Nrtd-
Check Number
t:h.*
amcunr
Permit NumberlC—ft
Rece/ t — Re/u,.MWlocated
coi mm
C.1-2
cok-2
C h-14
COMM5
Cck-6
Ckwwy
ColumM
CWu-9
2/18/2020
2/18/2020
Bude Smith Money Order
Robert Thacker Jr.
BancFirst
1628189"
$ 200.00
GP #74865D
GP i74808D
JD rct. 10829
PA rcL 9736
Trinh Thanh Luu
same
Chartes Schwab Bank
1365
200.00