HomeMy WebLinkAbout75885D - GrouseqVAMA / - i DREDGE & FILL NO. 75885
GPENERAL PERMIT Previous permit# A B C
Ls New DModification ❑Complete Reissue ❑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 H •
-� ❑ Rules attached.
Applicant Name �- �' 0 u.Sl2 _ Project Location: County 1? , � K
Address ln U Street Address/ State Road/ Lot #(s)
City /" Dt X State_XZIP 2--539
Phone # (�le�) ��c)2, 2Z�"� E-Mail '9�UL a� we S ( ) r16AA(6ubdivision
Authorized Agent �<<<- �,-k S cu City Ca , S ZIP -2-6`i(, �(
Affected ❑ CW �PEW CA[PTA ❑ ES ❑ PTS Phone # ( ) River Basin 1.,-6.
ElOEA ElHHF ElIH ElUBA ❑ N/A
AEC(s): Adj. Wtr. Body (nat art /unkn)
E. PWS:
ORW: yes / PNA yps no Closest Maj. Wtr. Body Qk k,Kij
Type of Project/ Activity ��,
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Pier
Fixed
Floati
Finge
Groin
BulU
Basin
Boat
Boatl
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A building permit may bl-riquired by: OceA✓, (-'At
( Note Local Planning jurisdiction) e-
Notes/ Special Conditions
or Awficant Printed Name Permit
❑ See note on back regarding River Basin rules.
Name
.-c A- ru
L "�
* Please read compliance statement on back of permit Signature
J
Fee(s) Check# Issuing Date
ti
?d
Date
Nerve of Property Owner RequemkV Permit
Mating Address: e7, For -74xa, T4P-j-"
Phone Number. -1.91q jo z 2-2
Email Address: =-- LJ6
1 M* that I have WOMMed -Agnid AwkS\
Agent / Con actor
W act on my behalf, for the purpose of applying for aril obtaining all LAMA permits
IV -f-
at my property k=W at -/ 7
in Qx rity.
I furtfmvmom certify that I am authorized to grant, and do in fact grant permission to -
Division of Coastal Management staff the Local PwTrNt Officer and thew agents to araer
an the afore"wnboned lands in conrwhion with evWtAwng ffdbrnokw - rekded to #w
perry* apphdobbri-
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CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property: 1
Agent's Name #: "X g,- -Z..J,-b�,-
Agent's phone #: .0 17t4b y
(Lot or Street #, Street or Road, City & County) /
Mailing Address: A � �-�fi�- CaO.)
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
_ they are proposing. A description or drawings with dimensions must be provided with this letter.
O have no objections to this proposal. ____ I have objections to this proposal,
-i If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this norm Contact information for DCM offices is
available at i tii /ti vv eflw(. -:F.�ir orbycalling 1-888-aRCOAST.
No response is conskbred lire some as no objee[!M dyrou bam bM noUlfed by CertWed Mell.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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 the appropriate blank below.)
/ "Wiy I do wish to waive the 15' setback requirement.
0,4 ,� 1 do not wish to waive the 15' setback requirement.
(Pypwner Information)
Signature
Print or Type AlAme
Malting Address
City/statelzip
Telephone Number / Email Address
Bate
(Riparian Property Owner Information)
Signature
I
�0 Lk 1a�� Chi �% J %4 C-P
Print or Tyhe3Name
91IS a 0 1 � - OL05e-
Mading Address
7
City/state/z*
Telephone Moog r/ Email YC�►e[`,
_5 /-9
Dale
(Revised Aug. 2014)
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