58127_PEDERSEN, LYNNE_20110629

__jr,AIVIA / ❑ DREDGE & FILL
GENERAL PERMIT Previous permit#
El 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
CityState ZIP
Phone # () 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
Project Location: County
Street Address/ State Road/ Lot #(s) :- .VL- , r
Subdivision
City ZIP `'
Phone # ( ) River Basin ! t�`/ ' 1, A 17to
Adj. Wtr. Body (nat /man /unkn)
Closest Maj. Wtr. Body
•
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Agent or Applicant Printed Name t j
Signature -- Please read compliance statement on back of permit
r
Permit Officer's Signature t
Issuing Date Expiration Date
Application Fee(s)
Check #
Local Planningf urisdiction Rover File Name

0 .
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
Iandowner(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

NO Division of Coastal Mgt. Habitat Impact Computer She:
Applicant: Lynne Pedersen
Date: June 29, 2011
General Permit #: 58127C
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
temp impacts
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
ow
Dredge ❑ Fill ❑ Both ❑ Other ®
390
390
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 ❑
252-808-2808 :: 1-888-4RCOAST :: www.nccoastaimanagement.net revised:02/03/10

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSIBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to L'V►\+\ e P e � CfSC'h is
(Name of Property Owner)
property located at 7017 n: < ,
(Lot, Block, Road, etc.)
on , in U T , E wA.\\ , 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)
(Applicant Information)
�0 lkx 1"\V
Mailing Address
City/State/Zip
Telephone Number
�)/3A
(Riparian Property Owner Information)
Signature
X L
Print or Type Name JJ
x 9(-1-
Telephone Number
X 615111
Date Date

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual applying for Pemmi
Address of Property:
7v 0
t:'h+1Z �t'bZ� S►�
0fa<v$,-A . N(, ),i 57
(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 letter.
I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coastal
Management 400 Commerce Avenue, Morehead City, NC, 28557 or call [phone] within
10 days of receipt of this notice. No response is considered the same as no objection if you
have been noted by Certified Mail. _
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, boatlift or sandbags
must be set back a minimum distance of 15' from my area of riparian access unless waived by
me. (If ish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
LX
I do not wish to waive the 15' setback requirement.
(Applicant Information)
PO 51,7A 1(10
Mailing Address
0 r , -C " 'A )IIC, 'W.71
City/state2ip
q 1- I i_j .x
Telephone Number
� 0/
Date \\�
of �Ax 6
Owner Information)
Print or Type Name
q�d-�Q�-gong
Telephone Number
Date

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l

s .e
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Michael F. Easley, Governor James H. Gregson, Director William G. Ross Jr., Secretary
Date -� Ij I
Applicant Name Lyi%1%e- t'c'�6S0N
Mailing Address 7y a, 5 0 \
I certify that I have authorized (agent) QX M ` r, V\C, to act on my
behalf, for the purpose of applying for and obtaining a1ll CAMA Permits necessary to
install or construct (activity) (, uy e l A � 0 A\ IV ,
at (location) 5'\w\
This certification is valid thru (date)
Signature! .��.' D
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled 110% Post Consumer Paper

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1092-11-7
1092-11-0
1092-11-5
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1092-11-8 Z "'*� A
1092-1.4-11
1092-14-10
1092-19-7
1092-19-6
PEDERSEN LYNN&B
49 PEDERSEN LY 4E B
1092-1 4-8 !
1092-1
SAagch
q,rX\ Oh16ty
1107
1092-14-9
1119
1092-17
Pamlico County, NC
*»1.yte? PROPERTY MAP
14 Dlacleimer:
The data provided on this map are prepared for the Inventory of real property found within
gMT Pamlico County, NC and are compiled from recorded plats, deeds. and other public records
a" and dots. This data Is for informational purposes only and should not be substituted
�rl/ trl4 for a true bile search, property appraisal, survey, or for zoning verification.
PEDERSEN LYNNE B
49
DGrIFDcr=r,I I VF.iRir= R
Parcel Number:
1092-14-8
Deed Book:
407
NC PIN:
6487600776
Deed Page:
38
Owner Name:
PEDERSEN LYNNE B
Plat:
N/S SR 1308
Owner Name2:
Owner Address:
7017 FAIRWINDS DRIVE
Deed Acres:
Land Value:
1.5
108000
Owner City:
ORIENTAL
Building Value:
392667
N
Owner State:
NC
Value:
500667
Owner Zip:
28571
Sale Date:
[unsupported data type]
Situs Address:
7017 FAIRWINDS DR
Sale Price:
0 One Inch
= 100 Feet
Legal Desc:
LOT 8 FAIRWINDS SUB

T
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7017 3airwmds ,'Dr
OrieHta4 r1VO28571
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