39695_SIMPSON, BILL_20040907

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INMAMA / ❑ DREDGE & FILL jz� -
GENERAL PERMIT <
Previous permit #
New __'Modification __lComplete Reissue CPartial 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
(I ❑ Rules attached.
1,
Applicant Name rltt" Project Location: County
c �r
Address t x _ Street Address/ State Road/ Lot #(s)
n
City 9* u�'�a • State /k ZIP - r, r I (r cy K -- "I.
Phone # ( ) 4 `� t� l ' Fax # O Subdivision
Authorized Agent cl W'` City 4' t' t _ ZIP / G'
- CW - EW ❑ PTA ❑ ES ❑ PTS Phone # ( ) River Basin
Affected F- OEA - HHF i- IH ❑ UBA ❑ N/A k r
AEC(s): Adj. Wtr. Body Uri, Ir ' r FF ` (nat /man /unkn) _
PWS: IFC: vp-
ORW: yes / no PNA yes / no Crit. Hab. yes / no Closest MaI. Wtr. Body
Type of Project/ Activity �'{ , , % /a(; ° A
(Scale: )
Pier (dock) le—h
Platform(s)_
Finger pier(s)_
Groin length
number
Bulkhead/ Rip
avg distz
max dirt
Basin, channe
cubic ya
Boat ramp
Boathouse/ B,
Beach Bulldo:
Other
Shoreline Len
SAM n,
Sandbags: n,
Moratorium:
Photos:
Waiver Attacl
A building permit maybe required by: Z' r j" , ! % ❑ See note on back regarding River Basin rules.
t
Notes/ Special Conditions ``1 n't ti % f E • j"�✓a� r ��` -
Agent or Applicant Printed Name Permit Officer's Signature
Signature ** Please read compliance statement on back of permit ** Issuing Date
Application Fee(s)
Check # Local PlanningJurisdiction
Expiration Date
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, certifythat this 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 (910-395-3900) 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

IL
6B_30,531 4825
137
william L Simpson
Susan W. Simpson
Lost Shoe Marsh DATE J Fl�--
P.O. Box 75 28516
ct. Beaufort. $ p p
` PAY TO THE 6;: N
ORDER OF DOLLARS
Q and lincwork. First Cltirens Bank logo on back. If not prescnl. Jo nol cash.
a- Look (or' NLcro Prml SiignaWm lint. gray yP
P CITIZENS 17
d CiFirst-Citizensry, 2B557
Bank d, Trust ComParry l f
MorohasN.C.
FOR - u� 0 4 8 2 5
1:0 5 3 L00 3001:00 L 3 L 7 2�+ 7 L 3 _.-
• • •

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOA TLIFTIBOA THO USE)
I hereby certify that I own property adjacent to 21 L-L- 5l MPSON
(Name of Property Owner)
property located at of W e-st FAG
(Lot, Block, Road, etc.)
on M&K ( R1Z in iR+e1� �b �� , 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 ISM wish to waive that setback requirement.
0
--------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development))
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------------------------------------------ -----------------------------------------------------
1^ Signature
Nd A e-cii©/J Ike Garner
An -�Ok S Print or Type Name
728-3068
Telephone Number
September 5, 2004
Date.

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to F:�� (-- [_- S l M PS0 iU is
(Name of Property Owner)
property located at C� w es-�- ' A`!�- k �',
n I, (Lot, Block, Road, etc.)
on l� ee , in �2 ��� D , 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 clo not wish to waive the setback requirement.
I & wish to waive that setback requirement.
------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be felled in by individual proposing development)
TV\e, ro 06eo� de�elo Pm 2m�" '� s 1,voodPrn woAkw� About
Pd�e Rrvel ROO �ee-t (ON wh��� would �e tn� ire
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