44286_CHIELEWSKI, HANK_20060214

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GENERAL PERMIT
-]Modification -]Partial
Previous permit#
C1New ❑Complete Reissue 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
[-1 Rules attached.
Applicant Name f 11/r :,,: �"
Project Location: County _
Address
Street Address/ State Road/ Lot #(s)
City u %�. L1 State �1i'C ZIP = ��(v • '
— - —
Phone # ( ) J Fax # O
Subdivision
Authorized Agent
City_ zip
CW :j EW L) PTA ❑ ES ❑ PTS
Affected
Phone # ( ) "�"'+ River Basin
ri OEA HHF F-j IH ❑ UBA ❑ N/A
AEC(s):
Adj. Wtr. Body_ c--i .% " gnat [man /unkn)
ORW: yes / no PNA yes / no Crit. Hab. yes / no
Closest Maj. Wtr. Body
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
SAM not sure
yes no
Sandbags: not sure
yes no
Moratorium: n/a
yes no
Photos:
yes no
A building permit may be required by:
Notes/ Special Conditions
(Scale: )
See note on back regarding River Basin rules.
Agent or Applicant Printed Name Permit Officer's Signature
Signature ** Please read compliance statement on back of permit Issuing Date
Expiration Date
Rover File Name
Application Fee(s) Check # Local Planning Jurisdiction

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 28405-3845
910-796-7215
Fax: [phone]
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
Revised 06/29/OS

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Postage
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Certified Fee
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Return Receipt Fee
(Endorsement Required)
Postmark
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Restricted Delivery Fee
(Endorsement Required)
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Certified Mail Provides: (asJeaaaJ zoos eunr ooae W,o� sd
■ A mailing receipt
■ A unique Identifier for your mailpiece
■ A record of delivery kept by the Postal Service for two years
Important Reminders:
■ Certified Mail may ONLY be combined with First -Class Mail® or Priority Mail®.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables, please consider Insured or Registered Mail.
■ For an additional fee, a Return Receipt may be requested to provide proof of
delivery. To obtain Return Receipt service, please complete and attach a Return
Receipt (PS Form 3811) to the article and add applicable postage to cover the
fee. Endorse mailpiece "Return Receipt Requested". To receive a fee waiver for
a duplicate return receipt, a USPS9 postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized aent. Advise the clerk or mark the mailpiece with the
endorsement "Restricted -Delivery".
■ If a postmark on the Certified Mail receipt is desired, please present the arti-
cle at the post office for postmarking. if a postmark on the Certified Mail
receipt is not needed, detach and affix label with postage and mail.
IMPORTANT: Save this receipt and present it when making an inquiry.
Internet access to delivery information is not available on mail
addressed to APOs and FPOs.

I hereby certify that I own property adjacrat to AW,��
(Name of Property Owner)
prop' located at %
(Trot Black, Road, etc)
an Av/��v zz L , in /'i� % ; r-L1} /yam �I%� j �/� C
(Waterbady) . (Town and/or County)
IL- has descnbed to me, as shown below, the development he is proposing ar tta: locadon,
and, I have no objections to his proposal. I understand that a pier; mooring
pilin�/boadiftlboathouse must be se: back a minimum distance of fift-I fe`t (IT) from my a+ -
of riparian access unless waived by me:
I do not wish to. waive the setback requirement
I da wish to waive t ur setback recuirement.
DESCRIPTION AND/OR DRAWE G OF PROPOSED DEVELOP-NLEN7:
(?'o be JUZed in by individual propoazn., development)
Signature
i;ANk ( n'1 N �y —
Print or Type Name-
Telephone Number

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