HomeMy WebLinkAbout76427D - Dodson?�CAMq► / 7(DREDGE & FILL
,ENERAL PERMIT
blew ❑Modification ❑Complete Reissue ❑Partial Reissue
N° 76427 A B
Previous permit #
Date previous permit issued
rized by the State of North Carolina, Department of Environmental Quality -7 ( 11
oO// �Oo
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC jT
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❑ Rules attached.
it Name D, ►'
o \y D Dd SG►'1 Project Location: County ��LAY\ S W I. Lk
D1410L 190ye Street Address/ State Road/ Lot #(s) 70044 F # �
Qo k 1� State., 06 ZIP 761-
E-Mail dAn,1rdcdfcr\
/�tal j/mow+
:ed Agent 'ftn1 r d /v ,^ l A.► 1
❑ CW XEW APTA )(ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes / no PNA `yes no
f Project/ Activity Gt
ck) length
atform(s) B , X log
Platform(s) z
ngth
tuber /
Oipraplength7
g distance offshorey'
w distance offshore
cannel
bic yardy
np
ise/ Boatlik
ulldozing
1- —1_ n A — - .I 1
S6;r S
e Length
not sure yes no ___
-ium: n/ yes no
yes no ..,,...
kttached: yes no
ng permit may be required by:
Local Planning Jurisdiction) ,
Subdivision
city DaLk _:t7S (ano( ZIP '�,T %
Phone # ( River Basin GF f
Adj. Wtr. Bod6� nat i
Closest Maj. Wtr. Body w
(Scale: I = d
��W h O 6%LK T_ ( � ❑ See note on�ckt regarding River Basin r
AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: ki
Mailing Address:
Phone Number: ? 6 76/3 - (/n�
Email Address: Atlp,\j PJ0(-)'6"\ ,,,J. Cpyyy
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: A"/ k �� /I "
r
at my property located at %U �ac►�ovl iJr- ,
in dratPjA County.
1 furthermore certify that 1 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
tint 6r ype ame
Title
i i "I llz�
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
(NanA6 of Property Owner)
I
property located at /(X2!1 /'Q5T �arJl•t �LJ —
pp (Address, Lot, Block, Road, etc.)
on c�eGk- OA-lr .-C w , in , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
I 'on.
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, 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. ;a"J
Oroperty Owner for tion)
G�
Signatf� A-� C'-�
Print or Type NaMe yb