39305_SHIRLEY, WILBERT_20040706

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�'•CAMA / DREDGE & FILL
GENERAL PERMIT
Previous permit #
JNew C'Modification ❑Complete Reissue '-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
E] Rules attached.
Applicant Name i • 1 , (�, ("r
Address -'• t:,• , .Ts• ev Z I
City L1/, J'
State ZIP Z, 7
Phone # Fax # ()
Authorized Agent
to . _ l�
Z CW
El EW 2 PTA ❑ ES ❑ PTS
Affected
AEC(s): OEA
❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
❑FC:
ORW: yes / no
PNA yes / no % Crit. Hab. yes / no
Project Location: County � �, 4t, r
Street Address/ State Road/ Lot #(s)
Subdivision
City f .l` W J-t ,� ZIP ?b S _j
Phone # ( ) River Basin
Adj. Wtr. Body @ia=t /man /unkn)
Closest Maj. Wtr. Body &C
Type of Project/ Activity tr.
w • c tin 140 a
I , s . i<
►
104AQ, )
1� ! jc,
, s..L J�wC. + f j,4�,
r (Scale: NGht )
-
Pier (dock) length t C • n
Platform(s) t 1 i r'`r
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length
av distance offshore
8
max distance offshore
Basin, channel
cubic yards -
Boat ramp
Boathouse/ Boatlift tin • c yf, 1 a
Beach Bulldozing
Other
Shoreline Length
SAM not sure yes no I
Sandbags: not sure yes (no i
Moratorium: n/a yes ono I
Photos: yes no
Waiver Attached: yes no
A building permit may be required by: �w„ rC1
Notes/ Special Conditions 1, vt.k v'a M
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on back regarding River Basin rules.
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Agent or Applicant Printed Name
Signature* Please read compliance statement on back of permit
Application Fee(s) Check #
r M r 1 td
Permit Officer's Signature
Issuing Date Expiration Date
Local Planning Jurisdiction 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
landowners).
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 (910-395-3900) for more information on how to comply with thesebuffer rules.
Division of Coastal Management Offices
Central Office
Mailing Address:
1638 Mail Service Center
Raleigh, NC 27699-1638
Location:
Parker -Lincoln Building
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293 / 1-888ARCOAST
Fax:[phone]
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)
Morehead City District
151-B Hwy. 24
Hestron Plaza II
Morehead City, NC 28557
202-808-2808
Fax: [phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico 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
910-395-3900
Fax:[phone]
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
www.nccoastalmanagement.net
Revised 10/05/01

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WILBERT SHIRLEY, JR. 2675
NCDL 2312785 PH 919-965-2006
P O BOX 311• 66-30/531
SELMA, NC 27576 Date 333
Pay to
Order 1 $ ,ZOO,
UP! __..-. Dollars 8 a��,.�
1ARST CITIZENS 333
BANK1,s101-1, Bank 8 Trust Company
S' W—, N.C. 27576
www �firstcitizens.com
For OzeAe
1:0531003001:003339655601ii' 02675 /
OCbrie gmerican GUARDIANOSAFETY YELLOW WYE

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFT/BOATHOUSE)
l,�
I hereby certify that I own property adjacent to ice;, j a D l A n A r s
(Name of Property Owner)
property located at b rJy
(Lot, Block, Road, etc.)
on , in iLW 10 c ,I , N.C.
(Waterbody) (Town and/4 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 IsQ wish to waive that setback requirement.
-------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
K/A>'e A va� L) i
7_e1/ %,F I 11 p I r u P r>
zzjA'6�'A.00
Signature
/,_ 1 T!AV ,I
Print or Type Name
Telephone Number
Date:

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to �, 1)sJtn
(Name of Property Owner)
property located at - r l v' -k
(Lot, Block, Road, etc.)
on , in NQ-VUeP.- �- 7 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 riparia access unless waived by me.
r I do not wish to waive the setback requirement.
v I dQ wish to waive that setback requirement.
--------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing dev�opment)
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Sign'ature
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Print or Type Name
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Telephone Number
Date:
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