59627_HARGIS, GERALD_20120111

1-1CAMA / ❑ DREDGE & FILL
GENERAL PERMIT Previous permit#
❑New []Modification ❑Complete Reissue El Partial Reissue 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 # O Fax # (
Authorized Agent
Affected ❑ CW ❑ EW ❑ PTA
AEC(s): ❑ OEA ❑ HHF ❑ IH
❑ PWS: ❑FC:
ORW: yes / no PNA yes / no
❑ ES ❑ PTS
❑ UBA ❑ N/A
Crit.Hab. yes / no
Protect Location. County
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP
Phone # ( ) River Basin
Adj. Wtr. Body (nat /man /unkn)
Closest Maj. Wtr. Body
Type of Project/ Activity
(Scale: w )
Pier (dock) length
Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length ,..;—
avg distance offshore
max distance offshor
Basin, channel _
cubic yards
Boat ramp
Boathouse/ Boatlift
I
—
1
�
i
e
i
+
I
-..._
-
—,
--
Beach Bulldozing
Other
Shoreline Length
SAY: not sure yes no
i
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
-
-- ---
-
r--x
_ .'
-'�
❑
See
note
on back regarding
River Basin
rules.
Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit **
Permit Officer's Signature
} ! j
Issuing Date Expiration Date;
Application Fee(s)
Check# Local Planning] 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:
❑ Tar - Pamlico River Basin Buffer Rules
❑ Neuse River Basin Buffer Rules
❑ Other:
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 Morehead City Headquarters
Mailing Address: 400 Commerce Ave
1638 Mail Service Center Morehead City, NC 28557
Raleigh, NC 27699-1638 252-808-2808/ 1-888-4RCOAST
Location: Fax: [phone]
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293
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

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Aaplicant:
Date:
t
I
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
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
tem acts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
Dredge ❑ Fill Both ❑ Othe
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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0067409 11-24 CASHIER'S CHECK 6740901416
Office AU a 1210(8)
Operator I.D.: ncOO5742
PAY TO THE ORDER OF ***NC DIVISION OF COASTAL MANAGEMENT'
***Four hundred dollars and no cents***
WELLS FARGO BANK, N.A.
5003 EXECUTIVE DR
MOREHEAD CITY, NC 28557
FOR INQUIRIES CALL [phone]
III 74090 L4 LE."I 1: L 2 L000 2481:486 L SO9644110
February 03, 2012
**$400.00**
VOID IF OVER USA$' 400.00
CONTROLLER

JAN-f09-2012 06:10 PH RICKS&HARGIS 336 224 9100 P.01
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JAN-09-2012 06:10 PN RICKS&HARGIS 336 226 9100 P.03
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ADJACENT RIPARIAN PROPERTY OWNER STA EMENX`
I hereby certify that I own property adjacent to (Name of Property Owner)
I
property located at 39 .v Air
_
(Lot, Block, Road, et ,)
1n N.C.
�
on 6 �E � ,
(Watcrbody) (Town and/or Cotpty)
Applicant's phone #:° -- Mailing Address:�i1��—,�I'� '
i
14e has described to me, as shown below, the development he is proposing At that location, and, I
have no objections to his proposal,
-- y~DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled In by property owner proposing development)
5 ER t~rr4�C�--------------------------------------------- -----
Owner A- (Riparian Proper Owner I for gtion) D
----
(information forProperty---P�1yln,g -- � � � �'1
for Permit) r, �4))44
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Si atu�e
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City/State/Zip Print or Type Name
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Telephone Number Telephone Number
S�gnaturo � to Date

JAN-09-2012 06:11 PM RICKS&HARGIS 336 226 9100 P.04
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
' acent to 0 S
I hereby certify that I own property adjacent (Name of Property Owner)
properly located at Ld V c ',z -"
(Lot, Block, Road, etc.)
in N.C.
on , (Town and/or Coun,y)
(Waterbody}
Applicant's phone 4: �.z Mailing Address:
It! C- .
He has described to me, as
shown below, the development he is proposing ahat location, and, I
have no objections to his proposal.
--- y- -
DESCRIPTION AND/Olt DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by property owner proposing development)
90 A OAS `or
_---------------
_------------
+• (Riparlan Property Owner Information)
(Information for Proper Owner Applying
for Permit)
Signature
Mailing Address
�C otD
5
_ 9� Print or Type Name
City/State/Zip
�1— .0' -.;"L®D Telephone Number
Telephone Number
Date
S gnature ate --

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