56992_MEDLIN, BELL_20101203

CICAMA / ❑ DREDGE & FILL
ENERAL PERMIT �*Previous permit#
❑New ❑Modification []Complete Reissue []Partial Reissue /J� Date previous permit issued
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
❑ Rules attached.
Applicant Name
Address
City State ZIP
Phone # (;) Fax # (�_)
Authorized Agent
Affected CW ❑ EW ❑ PTA ❑ ES ❑ PTS
AEC(s): El OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑ FC:
ORW: yes / no PNA yes / no Crit.Hab. yes / no
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP
Phone # ( ) River Basin
Adj. Wtr. Body (nat /man /unkn)
Closest Maj. Wtr. Body
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Agent or Applicant Printed Name
Permit Officer's Signature
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Signature ** Please read compliance statement on back of permit **
Issuing Date
Expiration Date
ii
Application Fee(s) Check # Local PlanningJurisdiction 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:
❑ 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
Raleigh Office
Mailing Address:
1638 Mail Service Center
Raleigh, NC 27699-1638
Location:
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293
Fax: [phone]
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888ARCOAST
Fax: [phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico Counties)
Elizabeth City District
1367 U.S. 17 South
Elizabeth City, NC 27909
252-264-3901
Fax: [phone]
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
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 08/09/06

a'c
rip licant:
D ate : � 9� 'I ?) Q
Describe below the HABITAT disturbances for the application
found in your Habitat code sheet.
All values shout match a name, an units aofmeasturte/mlen
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
ternimpacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge [] Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
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RECEINEL
NOV 2 2 2010
eF 1 ®CAA

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/«'RIVER FORM
Name of Individual applying for Permit:
Address of Property:
(Lot or Street #, Street or Road, City & County)
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, should be provided with this
I have no objections to this proposal.
If you have objections to ►vhat is being proposed, please )vrite the Division of Coastal
Management, Hestron Plaza H, 151-B, Hwy. 24, Morehead City, NC, 28557 or call (252) 808-
2808 within 10 days of receipt of this notice. No response is considered the same as no objection
if you have been notified by Certified Mail.
WAIVER SECTION
ing pilings, breakwater, boat house, lift or sandbags must be
I understand that a pier, dock, moor
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.
Signature Date
Print Name
Telephone Number With Area Code

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to gIf; L rrf�L) is
(� (Name of Property Owner)
property located at ��l �J O bv— ,©V
(Lot, Block, Road, etc.)
on 1'n C' OjN 1 , in Y-3 CP(pr , N.C.
(Waterbody) (Town and/or County)
Applicant's phonr#919).e5� `1" Mailing Address: f -6
� S-A IJ KL Q72)11
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
-------------------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by property owner proposing development)
eVCV -%ate Poil
�4
-ems 4:� 0
F ax>
(Information for Property Owner Applying
for Permit)
Mailing Address
City/State/Zip
Telephone Number
Signature Date
(Riparian Property Owner Information)
I �Jl, e � J-[�--� -
Signature
Aj�"( d #la —
Print or Type Name
Telephone Number
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
F1ZL rYl�L1t �s
(Name of Property Owner)
lll()
f 2 <U10
property located at 1 4 3 �
(Lot, Block, Road, etc.) flock
on !MW c.�R PAL_ Jn _!�.0 WC4. CNOF WE , N.C.
(Waterbody) (Town an/or County)
Applicant's pho #: �''�r� Mailing Address:
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by property owner proposing development)
j
ao
(s (-r I
(In ation for Property Owner Applying
for Permit)
Mailing Address
City/State/Zip
Telephone Number
Signature
Date
---------- 1---------- ----------- - -_------
(Riparian Property Owner In ation)
�Signa�tue
i
Print or Type Name
Telephone Number
Date

<,K
SAMMIE E. TURNER
MARINE CONSTRUCTION ACCT
252-725-3415
P.O. BOX 1885
MOREHEAD 0
4976 I!
66-112/531!
TY, NC 28557 I
PAY DATETO THE
ORDER OF -.lbb
Oe
DOLLARS
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} ; BRANCH BANKING AND TRUST COMPANY
1-800-BANK BBT BBT.com i
FOR ` ' l0
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