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DCAMA / F-1 DREDGE & FILL N? 51- 12 CC
GENERAL PERMIT Previous permit 4 —
[--]New E]Moclification ElComplete 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 Project Location: County
Address Street Address/ State Road/ Lot #(s)
City State ZIP
Phone # Fax # O Subdivision
Authorized Agent City ZIP
Affected El CW El EW D PTA El ES [:1 PTS Phone# O River Basin
AEC(s): El OEA [I HHF El lH El UBA El N/A Adj. Wtr. Body
El PWS: EJ FC:
ORW: yes / no PNA yes / no Crit.Hab. yes no Closest Maj. Wtr. Body
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Agent or Applicant Printed Name
Signax ure . "Please read compliance statement on back of permit"
Application Fee(s) Check #
Permit Officer's Sjgnature
Issuing Date
ExpiraVl6n Date
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 (252-946-648 [)or the Wilmington
Regional Office (9 I 0-796-7215) 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/ I-888-4RCOAST
Location: Fax: 252-247-3330
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293
Fax:919-733-1495
(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: 252-264-3723
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Washington District
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Fax: 252-948-0478
(Serves: Beaufort, Bertie, Hertford, Hyde,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext.
Wilmington, NC 28405-3845
910-796-7215
Fax:910-395-3964
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
Revised 08/09/06
k ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER 3110ORING PILINGSIB OA TL.[F, TIB OA TFIO USE)
I hereby certify that I owrr property adjacent i.o Zr,;,- Li SA G ow— s
( Sarno of Property Owner)
property located at 3-153 10 y r.-,_ m{- r4mot
(Lat, Block, Road, etc.)
on a ppm5 e�g= , in Ca' , N.C.
(Waterbody) ( own 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 (I T) from my area of riparian access unless
waived by me. (If you wish to waive the setback, you trust initial the appropriate blank
below.)
I do not wish to waive
I do wish to waive that setback requirement_ MAY 2 3 2008
-------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRA`VING OF PROPOSED DEV� O
(To be filled in by individual proposing developmen t`)1
.� t c 1-i
r
00
A ,
prr yo X-f cfteNG po 6,l1-
� City uum
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-----1111-------------------- '------------'---------------------- - �iL11%fit
Signature
Z (�j Print or Type Name
Telephone Number
Date: V ��
llf! .Gdi`-Jwl Depa !II''iKU:
Michaei ` Easley, Governor Chafles S. ,cones, Mractor Wiliam G. Ross Jr., Secret iry
Date
Applicant Narae _ -yQ 0
Mailincr Address
1 C r. a
MAY 2 3 2008
- 5-1y 1 F rehear L;ity CCM
7 7 �,, pp ( i - to act on M—v
,Y-ertify that A have autLL2oe i��;a �`d�e�l L) �.j•o- �,�r• .-•i/`? % �iJ �f• =-S
behalf, for the purpoSe as applying for and obtainbain
cr all CAMA. Permits Recessary to
install or eaxastruct f actil ity) 01ir
at
i
This ceriRzication is valid t
'
I
i
MAY�JE1 -
uteri .vi
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERNIOORING PILINGSIBOATLIFTIBOATHO USE)
is
iV
I hereby certify that I owa property adjacent +.o J&, 1-1S,9 G'A, IS
(-vame of Property Owner)
property located at �6
(Lot, Block, Road, etc.)
on A pAg5 (r-gods = , in 4O N.C.
(Waterbody) ( own 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 I boatlift / boathouse
must be set back a minimum distance of fifteen feet (15') from my area of ripan'
waived by me. (If you wish to waive the setback, you must initial the appro Fh
below.) i
I do not wish to waive MA.Y 7pQ8
I do wish to waive that setback requirement.
------------------------------------------------------
DESCRIPTION AND/OR DRANVING OF PROPOSED D
(To .be filled in by individual proposing develop
Iq L-
Ap 4.1 pT' 71�
----- -!4)- �--
G
morah d city U G M
Signature
Print or Type Name
31 - 3 9 cog
Telephone Number
Date: 5 - 2/ 1
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