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HomeMy WebLinkAboutSalsbury, Mary 76708C:AMA / ❑DREDGE &FILL 1`i_)8 A B �C` D NERAL PERMIT Previous permit# a' ew El Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued As authorized by the State of North Carolina, Department of Environmental Quality iL - and the Coastal Resources Commission in n a environmental concern pursuant to 15A NCAC l ❑ R les attached. Applicant Name )�� �� Project Location: County Address City Phone # Authoriz Affected 4w AEC(s): ❑ OEA ❑ PWS:_ ORW: yes / no ❑� _,L5:ffA DES ❑PTS ❑ HHF ❑ IH ❑ UBA ❑ N/A PNA / yes/ no Type of Project/ Activity Pier (dock) length Fixed Platform(sl"Aa_(__ Floating Platform(s) Finger pier(s) Groin length number Bulkhead/ Riprap length_ avg distance offshore_ max distance offshore Basin, channel cubic yards_ Boat ramp Boathouse/ Boatlift Beach Bulldozing Other Shoreline Length A SAV: not sure yes Street Address/ Sta rRoad/t Subdivision City ZIP Phone # (_) River, Basin Adj. Wtr. Body U - �� re- ` c man /unkn Closest Maj. Wtr. Body O-A W IA (} 1 Z i7x ' Moratorium: n/a yes n' Photos: yes no Waiver Attached: yes no A building permit may be required by:� ( Note Local Planning Jurisdiction) Notes/ Special Conditions (Scale: ) See note on back regarding River Basin rules. 6.a' Li ✓' f -Z e G Agent or Applicant Printed Name PermitOffi Print d Name Sign "Please read compliance statement on back of permit** Sign at re pp ication Fee(s) Check # Issuing Date pp Date ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I hereby certify that I own property adjacent to P lQ C I _ 's (Name of Property Owner) property located at U �, ^ ddress, Lot, Block, Road, etc.) l on t J j C,k `S � .i -,in C'r 1c,) c V C d -e_c , N.C. (Waterbody) (City/Town and/or County) The appl' ant has described to me, as shown below, the development proposed at the above locatio . 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) ' 1 lu , ,. WAIVER SECTION I unerstand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin mus 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. —LQ Telephone Number/email address ( �' �7 �s5 + (A Date �I �17-�► �� �• 4� �.�> c� (Adjacen rope rtSi wrier Information) Signat re ' �LLL' Print or Type Na e /D g f horsy `^t Mailing Addr ss r, �e��,&C City/State ip 5f0 Telephone Nu ber/e ail address s 20 Date* *Valid for one calendar year after signature* (Revised Aug. 2014) ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I hereby certify that I own property adjacent to property located at H Property O ner) I , (A�Idress, Lot, Block, Road, etc.) on , (C' _g k , in G ) U c � c��'� e-A( , N.C. (Waterbody) (City/Town and/or County) The applicant has described to me, as shown below, the development proposed at the above locatio �s 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) RecF tV APR 2 8 NN ®cwj pmvj , w..... .:.__, • ......,._....,-....r._-.� a ._,<- _.__y. i 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) Signature L) J`' T- Print or T pe Name Mailing� Address f City/State/Zip rn�i�� I'K1C Te phone Number/email address Date (Adjacent Property Owner Information) ignatur * 1 Print or Type Name ailing Addre s Ci / tatelZip Te—Done Number / email address`" Date* (Revised Aug. 2014) *Valid for one calendar year after signature* AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION f Name of Property Owner Requesting Permit: V, , `` od r \ 1 j J Mailing Address: g0 Phone Number: Email Address: I certify that I have authorized / 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 C�� ,� i i in = (-7Le t'e 1-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 Aa"JI-7. r `1s . U- 1 Print or Type Name ('-) l kt' 1 ':C Title -_ l�lo Date This certification is valid through I / APR �Z tj r�U1,0 Qc tiITY f � I@r t t n U A A P 'O F V D F ' I MU MI 0- � � s' ;' ; � � - 1 r I � � � � +" -u — � � '6 - �� .; - - 3 � ' I� .:,.� � _ _s. - � � �.� �� �� I � > ._ �. �. �,�} �� �; � _ _� � �.� � _... -� .I C• _ _ pp fi (f� -- -__- _ ._:. __.._ ...,.... r� .,...... �_. .� _ - _e_. �... -�. � _. �ir , r ,a..xrt �„ .. �� I� ,r: I � ,.s __ .�-. _. �� � .. �,,, --. .. __ } ._ , � �.