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
__
.�-.
_.
��
�
..
�,,,
--.
..
__
}
._ ,
� �.