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11 CAMA / ❑ DREDGE & FILL ' I
GENERAL PERMIT Previouspermit#
[]New ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources i
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
❑ Rules attached.
Applicant Name j -c"i\k ✓c:or 4, C., s
Address -
City (y\ �, t t �J.A- State °` C ZIP ASS �=
Phone # ( - )) `J$- 11 S` 7 Fax # ( )
Authorized Agent ( & ,4 �; 5-a Od wel
•+..
Affected ❑ CW IC EW X PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
AEC(s):
❑ PWS: ❑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
.r-
cubic yards
Boat ramp
Boathouse/ Boatlift X
Beach Bulldozing `
Other
Shoreline Length
SAM not sure
yes
n�
Sandbags: not sure
yes
no:
Moratorium: n/a
yes
no
Photos:
yes
no,,
Waiver Attached:
yes
no i • --
A building permit may be required by:
Notes/ Special Conditions
o6U)��
Agent�r_Applican``t Printed�� Name
Signature Please read compliance statement on back of permit
Application Fee(s) Check #
Project Location: County t r-v\
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP
Phone # ( ) River Basin
Adj. Wtr. Body V� (nat /man /unkn�
Closest Maj. Wtr. Body
(Scale:,Ljo SeGt(q)
® See note on back regarding River Basin rules.
e4irmit Officer's Signature
/- /o -off 1!- /0- a
Issuing Date Expiration Date
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:
1 J Tar - Pamlico River Basin Buffer Rules ❑ Other:
[J 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: Fax: [phone]
Parker -Lincoln Building
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293
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,
Orslow -below New River Inlet- and
Pender Counties)
Revised 06/29/05

h
NCDENR
North Carolina Department of Environment and Natura
Division of Coastal Management
Michael F. Easley, Governor Charles S. Jones, Director
Date 1,1X9 D
Applicant Name
Mailing Address
fo. -q7
Resources
William G. Ross Jr., Secretary
I certify that I have authorized (agent) to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
-7
install or construct (activity) U/9- i
at (location) � L ✓�
This certification i valid thru (date
Signature,
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] \ FAX: [phone] \ Intemet: www,nccoastalmanagement.net
An Equal Opportunity \ Affirmative Action Employer— 50% Recycled \ 10% Post Consumer Paper

ADJACENT .I'ARLAN PROPERTY 0�N-IN-ER STA`I EINIEN i
1 he- e:)y certify that I own property adjacent to _,AAA M K V Olj C 's
+; ame of Property Owner
prope. ty lacat� at VC 3J A u A T, L Gp AA MIT T-
(Lot, Block, Road, etc.)
01i -BALL C��C/L , in /'lil E,eAT ? T N.c.
(Waterbody) (Town and/or County)
He has described to me as shown below, the development he is proposing at that locanion;
and_ I have no objections to his proposal.
DE-"SCRIMO J ANND/OR DR.AR-DiG OF PROPOSED DEVELOPIN ENT
(To he filled in by indiWdual proposing development)
�oPos�b
IK K
pGiC
Signature
rin Tyke
' Te;ephont N;mbe-
Date. l Z

ADJ CEN'.t' RIPA.RLAN PROPERTY ONVIN-E . STATEINLENT
T hLe: e;)y certify that I own property adiacent to )9Ak K. (IO to 4-t LCr:5 s
(.Name of Property Owner)
property iccatvd at
(Lot, Block, Road, etc.
oil in Mc.
(Waterbody) (Town and/or ounty)
Pe has described to me as shown below, the development he is proposing at that locadon.
and- I havc no c;bjections to his proposal.
D ES CR.IPTION A -NL -D/OR DRA'W-Di G OF PROPOSED DEVELO P V E'_VT
(To be filled in by individual proposing development)
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