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CAMA / ❑ DREDGE & FILL.'
GENERAL PERMIT Previous permit#
LiNew ❑Modification h:Complete Reissue ❑Partial Reissue Date previous permit issued
I
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
' El Rules attached.
Applicant Name
Address (_
`✓ i (,'. C IJ ,` i
City �' �
State f\,' . ,,
ZIP
Phone #
Fax # O
Authorized Agent
Affected J CW
❑ EW FD PTA ❑ ES
❑ PTS
AEC(s): L7 OEA
H H F C' IH 7 UBA
❑ N/A
:1 PWS:
71 FC:
ORW: yes / no
PNA yes / no Crit. Hab. yes / no
Type of Project/ Activity
Pier (dock) length
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
;r
Shoreline Length —
SAV: not sure yes no ,
Sandbags: not sure yes not
Moratorium: n/a yes no
Photos: yes (-Yf6"
7.
Waiver Attached: yes 'no) - - --
A building permit may be required by: _
Notes/ Special Conditions
Agent or Applicant Printed Name
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision
CityZIP
Phone # ( ) __ River Basin
Adj. Wtr. Body_ gnat /man /unkn)
Closest Maj. Wtr. Body
(Scale: i )
. J
Ate
See note on back regarding River Basin rules.
Signature
Signature Please read compliance statement on back of permit
Application Fee(s) Check #
Issuing Date Expiration Date
Local Planning Jurisdiction 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, certifythatthis project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
❑ 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 (910-395-3900) for more information on how to comply with thesebuffer 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 / 1-888ARCOAST
Fax: [phone]
Fax: [phone]
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Morehead City District
151-13 Hwy. 24
Hestron Plaza II
Morehead City, NC 28557
202-808-2808
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
910-395-3900
Fax: [phone]
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
www.nccoastalmanagement.net
Revised 10/05/01