76554D - Thagard

CAMA >f-] DREDGE & FILL N9 76554 A B
;ENERAL PERMIT Previous permit #
'.New Modification ElComplete Reissue Partial Reissue Date previous permit issued
•ized by the State of North Carolina, Department of Environmental Quality
;oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
�Rulles atgched.
:NameL✓ Q ' (.&
�� Project Location: County Ill�, 9)-
f Street Address/
/State Road/ Lot # s)
C/ -stateZlP ( G,`
Subdivisiors
i
ed Agent 1/1 (,Q Y City ZIP /, l
❑ CWW V$lTA N5 ElPTS Phone # Ri er Basin
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body GI S SG
ElPWS. nat
yes / (/ PNA yes no
' Project/ Ac
:k)length
aform'N
Platform4
ier(s)
ngth
nber
raplength ?
distance offshor
x distance offshore
cannel
rip.
se/
ulldozing
e Length
not sure yes
cum: n/a yes
yes o '
kttached: no
ng permit may be required by:
I nral Plannina lurisdirtinnl
Closest Maj. Wtr. Body
(Scale: ) Ce
❑ See note on back regarding River Basin r

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Leooard
Mailing Address: J62i �J_ rd '17vecl
Phone Number:
Email Address:
I certify that I have authorized
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to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: &S' E-e-%c�
at my property located at
in County.
I furthermore certify that / 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:
Signat
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Print or Type Na5ie
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Title

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to e 6 Qelr (I s
,
,/ J (Name of Pro Owner)
property located at 32 5 T rCl �7 ee
On 1 (Address, Lot, BloZ(City/T
Ro d, etc,)
in r , N.C.
(Waterbody) and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location,
1 have no objection to this proposal.
ri
sir I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fll1 In description ba6w o+`46000 a she drawing)
See %%+�c-lleri l%l2ta),rK�
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 belay.)
---C- =I_ I do wish to waive the 15' setback requirement.
nC- - I do not wish to waive the 15' setback requirement.
(PrtY Owner Information) (Adjacent Pro
Party Owner Information)
_
Sztut�re ............
Szgizutur
Print or Type -Name
4 2-,Q l e J Pry n or (Type Name
i r y 11 5 , „-• N /+s of (/ I �.') 1,-.1l 7� i/ fl • �r

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to o-( n 's
(Name of Prope Owner)
property located at . �TI e�
(Address, Lot, Block Ro d, etc.)
on __(Ltl1Cl l in t r , N.C.
(Waterbody) PtYMANn andlor County)
The applicant has described to me, as shown below, the development proposed at the above
locatign.
__!__p I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must Rli in description below or attach a site drawing)
See
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.)
JeJ I do wish to waive the 15' setback requirement.
It- I do not wish to waive the 15' setback requirement.
(Pro erty Owner Information) (AdjaLPrope Owner information)
Signature Signatur *
kLm r c4 �! �r . ��EA � '-� ALL
Print or Type Name Print or Type Name
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