55214_RICHARD, ROSS_20100325

❑ CAMA / F: DRE OGE & FILL
GENERA` PERMIT ��
Previous permit#
❑New ❑Modification ❑Complete Reissue ❑Partial Reissue
Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural deso.2ces
- ,_ 1 j KI)o
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
3JRules attached.
Applicant Name . O,j tit .� (h Project Location: County 21 ,''- } 1 1^ 0
Address � " `� �?� (' �`�l E'j e(It 1(Jr Street Address/ State Road/ Lot #(s)
City ; :: ; t 11 t, t0 it StateZIP
Phone # O'_. Fax # O Subdivision
�J
Authorized Agent j �, (°�tr,r;► ( ,-'� (� t� (� i' ali lfict City ; v r�� , '�
I ZIP
ElCW � EW D PTA El ES ElPTS Phone # ( )
Affected
River Basin
/ Q
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
AEC(s): Adj. Wtr. Body
w L...V
(nat /man /unkn)
❑ PWS: ❑FC: ,J
Closest Maj. Wtr. Body ;4 k LA-,(,- i�-
S U �A
ORW: yes / no PNA yes / no Crit.Hab. yes / no
Agent or. Applicant Prin d Name Permit Officer's Sin ure
Signature Please read compliance statement on back of permit Issuing Date / f Expiration Date
ApplicationFee(s) Check# Local PlanningJurisdiction Rover File Name f

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 consistentwith 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 howto complywith 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

e 1
ems- j�
North Carolina Department of Environment and Natural Resources,
Division of Coastal Management
Ivli&,aei F. Easley, Gow-w-ior Charles S. Jones, Director William G Ross Jr, Secretary
Date "'Die. ar ,If
Applicant Name USS
---
Mailing Address 104/7 ARLty �jCAf-- qa
JUT
I certify that I have authorized (agent) Z&&D to act on my
behalf, for the purpose of applying for and obtaining all CAI4IA Permits necessary to
install or construct (activit)-1
at (location)
This certification ' alid thru
Signature
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] FAX: [phone] l Internet www.nccoastaimanagement.net
An Equal Opportunity 1 Affirmative Action Employer — 50% Regcled 110% Post Consumer Paper

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to .kO-55 4 ka rell-1 Rich fi 's
property located at
zr
(Name of Property Owner)
(Lot, Block, Road, etc.)
on 11 lJ� �' in Rc rn 4 o G d UIVI N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location,
and, I have no objections to his proposal. I understand that a pier/mooring pilings/boatlift/boathouse
must be set back a minimum distance of fifteen feet (15') from my area of riparian access unless
waived by me.
I do not wish to waive the setback requirement.
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
W
�'Q c G►� �� u. r► n
DOCK.
Y.� J 9 7,,/ /2, V 1 i
L Telephone Number
Date: -3 /1 'q / k-z>

BROAD CREEK CONTRACTING INC
PO BOX 88
MERRITT, NORTH CAROLINA 28556
[phone]
PAY I
TO THE �
ORDER OFF +
0
First South Bank
'', GRANTSBORO, NC 28529-9447
FOR \U,,�� r �'
u'0000 1 2 500 1: 2 5 3 1r 7 b E 2 111:
C38009577
1250
a9Wd-CheckFmW
V
7 �^, 66-7162-2531
DATE
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rm

NC Division Coastal Mgt. Habitat Impact Computer Sheet
Applicant: Ross Richard
Date: March 25, 2010
General Permit #: 55214C
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
im act amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
OW
Dredge ❑ Fill ❑ Both ❑ Other X
270
270
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 ❑

UNITED STATES POSTAL SERVICE
First -Class Mail
Postage & Fees Paid
USPS
Permit No. G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
Bfcd
D. XKc
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• Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
• Print your name and address on the reverse
so that we can return the card to you.
• Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
GAY I -es ver
Lq
4-rop -rn V1, te
11-701
A. Signature}
)
X Agent
11 Addressee
B. Recei4d W'PHnItt C. Date of Delivery
D. Is delivery address different from item 1? 0 Yes
If YES, enter delivery address below: 11 No
3. Service Type
11 Certified Mail 0 Express Mail
13 Registered 13 Return Receipt for Merchandise
13 Insured Mail 13 C.O.D.
4. Restricted Delivery? (Extra Fee) 13 Yes
2. Article Number
(rransfer from service label) 7007 0710 0001 5273 2455
i PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540
i