58612_KHAN, ALI_20111103

❑ CAMA / ❑ DREDGE & FILL
GENERAL PERMIT Previous permit# 'i. `~
❑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
I
Address
City
Phone # (`) _
Authorized Agent
Affected
❑ cW
AEC(s):
❑ OEA
❑ PWS:
ORW:
yes / no
_ State ZIP
Fax # ( )
❑ EW ❑ PTA ❑ ES ❑ PTS
* HHF ❑ IH ❑ UBA ❑ N/A
❑ FC:
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
Type of Project/ Activity
Pier (dock) length
Platform(s)
i
Finger pier(s)
(Scale: )
-
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
i
I
I
Shoreline Length -
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
❑ See note on back regarding River Basin rules.
Agent or Applicant Printed Name Permit Officer's Signature i A
Signature ** Please read compliance statement on back of permit Issuing Date Expiration Date
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 Morehead City Headquarters
Mailing Address: 400 Commerce Ave
1638 Mail Service Center Morehead City, NC 28557
Raleigh, NC 27699-1638 252-808-2808/ 1-888ARCOAST
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