44297_RHODES, SHELTON_20060216

F !CAMA / ❑ DREE7GE & FILL
GENERAL PERMIT
❑New ❑Modification ❑Complete Reissue ❑Partial Reissue
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
Previous permit #
Date previous permit issued
CI Rules attAched.
Applicant Name -) P L,�' ► ` � C. `"�' Project Location: County
Address ` oo Street Address/ State Road/ Lot #(s)
City ✓� } '- ^ State ZIP
Phone # (;' `) .
" �/�
u `� �` Fax # O
Subdivision
_
Authorized Agent
City
ZIP
CW
__�? A ❑ ES ElPTS
Phone # (. )
River Basin
�"` f
Affected
-OEA
AEC(s):
_DEW
❑HHF ❑IH ❑UBA ❑N/A
{�.,
Adj. Wtr. Body__
;�. x, /
�)t_ ,,
_ . �Kat ,/mom an /unkn)
J PWS:
❑ FC:
']
Closest Maj. Wtr. Body
ORW: yes / no
PNA yes / no Crit. Hab. yes / no
Type of Project/ Activity
Pier (dock) length ! L �
Platform(s)_ -' 0
Finger pier(s)
Groin length
number
Bulkhead/ Ripraplength
avg distance offshore
max distance offshore
Basin, channel
cubic yards
Boat ramp �- —�
Boathouse/,oatli
Beach Bulldozing
Other
Shoreline Length VC
SAV: not sure yes no
Sandbags: not sure yes no
Moratorium: n/a yes no
Photos: yes no.
Waiver Attached: yes no
A building permit may be required by:
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
� L)
Application Fee(s) Check #
i_.
(Scale: /
See note on back regarding River Basin rules.
Permif`Officer's Siggnatu re
suing Dati I Expirati- n ate
Local Planningf urisdiction Rover File Name

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that 1) prior to undertaking any activities authorized by this permit, the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s) .
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
D Tar - Pamlico River Basin Buffer Rules ❑ Other:
❑ Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Quality. Contact the Division of Water Quality at the Washington Regional Office (252-946-6481) or the Wilmington
Regional Office (910-796-7215) for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Central Office Elizabeth City District
Mailing Address: 1367 U.S. 17 South
1638 Mail Service Center Elizabeth City, NC 27909
Raleigh, NC 27699-1638 252-264-3901
Location:
Parker -Lincoln Building
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293
Fax: [phone]
Fax: [phone]
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Morehead City District
400 Commerce Ave
Morehead City, NC 28557
202-808-2808/ 1-888-4RCOAST
Fax: [phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico Counties)
Washington District
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Fax: [phone]
(Serves: Beaufort, Bertie, Hertford, Hyde,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext.
Wilmington, NC 28405-3845
910-796-7215
Fax: [phone]
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
Revised 06/29/05

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SIGNED_
FORM 4003

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATMOUSE)
I hereby certify that I own property adjacent to
property located at
e /A/ v 4 To '-a'
(Name of Pro
E
i
(Street Address, Lot, Block, Road, etc.)
on � �� � P r6J d � Ie Morehead .C. DCM
,.
,in � ,
(W t rbody) (Town and/or County)
He/she has described to me, as shown below, the development he/she is proposing at that
location and I have no objections to this proposal. I understand that a pier/mooring
pilings/boatlift/boathouse must be set back a minimum distance of fifteen feet (15') from my area of
riparian access unless waived by me. I have indicated my intentions by initialing below:
I do not agree to waive the 15' setback requirement.
I do agree to waive the 15' setback requirement.
s)
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
fu0
Sig ure
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Print or Type Name
1119,5z-a11//1 37<15-
Telephone Number
Date: Z " '/- 0(,

,ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOArTH/OUSE)
_ pa's
I hereby certify that I own property adjacent to ���
/ (Name of Proper
2966
property located at 5e&A1/10-
e1
(Street Address, Lot, Block, Road, etc.) FEB p 9 2006
on SoL4MCI ,inEA-1vP-JJ 1 Le Mon--%,J1dt
aterbody) (Town and/or County) y DCM
He/she has described to me, as shown below, the development he/she is proposing at that
location and I have no objections to this proposal. I understand that a pier/mooring
pilings/boatlift/boathouse must be set back a minimum distance of fifteen feet (I T) from my area of
riparian access unless waived by me. I have indicated my intentions by initialing below:
I do not agree to waive the 15' setback requirement.
�,nitiAs)
XA, I do agree to waive the 15' setback requirement.
(initials)
-----------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
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