42929_JALOSZYNSKI, JACKIE_20050919

❑ CA,MA / ❑ DREDGE & FILL I
'r
;LIEN ERAL 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 Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
❑ Rules attached.
Applicant Name
Address
City State ZIP
Phone # (i) ` Fax # (,)
Authorized Agent
Affected El CW Q'EW E PTA
AEC(s): EJ OEA ❑ HHF ❑ IH
❑ PWS: ❑FC:
ORW: yes / no PNA yes / no
Type of Project/ Activity
Pier (dock) length
Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
cubic yards_
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
Shoreline Length
SAV: not sure yes
no
Sandbags: not sure yes
no
Moratorium: n/a yes
no
Photos: yes
no
Waiver Attached: yes
no
A building permit may be required by:
Notes/ Special Conditions
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision
City ' ZIP
❑ ES ❑ PTS Phone # ( ) River Basin
❑ UBA ❑ N/A Adj. Wtr. Body (nat /man%/unkn)
Crit. Hab. yes / no Closest Maj. Wtr. Body
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit'��
Application Fee(s) Check #
(Scale:
❑ See note on back regarding River Basin rules.
Permit Officer's Signature
Issuing Date
Local Planningf urisdiction
Expiration Date
Rover File Name

s
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 (252-946-6481) or the Wilmington
Regional Office (910-796-7215) for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
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
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
400 Commerce Ave
Morehead City, NC 28557
202-808-2808/ 1-888-4RCOAST
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 28405-384S
910-796-7215
Fax: [phone]
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
Revised 06/29/05

41
SEP 0 8 Z005
ADJACENT RIPARIAN PROPERTY OW M STA� DCRA
(FOR A PIERIVNCOVE)ED BOAT' U.M
I hereby certify 'that I own property adjacent to S�ic` �?g 103r a VNs - s
(Name of Property Owner)
property located at_ /13 1c o r w
(Lot, Block, Road, etc.)
on _ ` 4 i✓fl , in 1 / �✓ r '0 i✓ o// S'�o r F.s , 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 objoctions to his proposal. I understand that a pier/uncovered boat lift
must be set back a minimum distance of fifteen feet (I5') from my area of riparian access unless
waived by me.
I do not wish to waive the setback requirementP r
I AQ wish to waive that setback requiremente,, r f� F a. c,(
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be JWed in by individa4l propoosing� development) �+
D /� -�-# / \ �q/Doc A /�rJ r0'
o-(' f�,✓r kNo���hcrES
Print or Type Name
Telephone Number
Date_
roo(M
DIH3 SLL9 9ZL ZSZ YV3 SS:91 Soot/U/90

11iiq . -
6
SEP 0 8 2005
Morehead City F)CM
ADJACENT RIPARIAN PROP,Qt1'Y Owmm STATFmmT
(FOR A PJWVNCOVERFD BOAT LJFJ)
I hereby certify that I own proprty adjtl mt to TAck# F 3 c �o.r 7 vas �+` Is
(Kam of Propesfy Owsto
property looted at
coot, Blod4 Rmd, etc.)
on i�i✓ . in _ 1 / �' F %✓ o �/ S.Co T Fs N.C.
(Wsterbwy) (Town aod/or County)
He has described to me, as shown bdVw, the developn arts he is pn4m&g at that
locatiwa, and, I have no objections to his popont I undersW4 dw a pier/wwo Wend bout left
must be set back a minimum distance of fiilvm fat (15') hum my area of riparian access unless
waived by me.
JAI" with to waive the sedw taquirunalt: F'r -f G. F ��c �(
I da wish to waive that s Wmcic requireamentec, ►- 4-Ai:- 4a c k,
D ON AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be jUW in by 4"w"d pmppodxg drnloptret�et)
!�O
$ipatum
Ol;.t/ I -A S;-t c 0
Print of Type Name
7dephoac Number
'�-o ��a s-
Ar )
Z001A DIH3 5LL9 9% ZSZ Xdd 9s:9T SOOZ/CZ/80

ERIC 13. ELLIS
JASA M. ELLIS PH [phone]
205 NOT-nNGHAM DR-
MOREHEAD CffY, NC 28557
Pay to the I//-- /, � ff /(,
3107
66-30/531
133
Order of —
Dollars
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RS-F CITIZENS-
BANKF,,' -C
Atla'M, 5 h. N'C . 29512
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For—i4gm4�� 0310?
1:053 0030
Date
4