54331_CK, GOOSE_20090720

49AMA / D DREDGE & FILL 9
CIEWERAL. PERMIT Previous permit #
❑New ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued l
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
O Rules attached. j
Applicant Name
Address
City fir, r�r State f a}. ZIP
Phone # (`) Fax # ( )
Authorized Agent w S
Affected CW EW 11 PTA 13 ES �TS
AEC(s): El OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑FC:
ORW: yes / no PNA yes / no Crit.Hab. yes / no
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision
ZIP
Phone # ( ) River Basin
Adj. Wtr. Body / wa'1p ;tat. /mom an /unkn)
Closest Maj. Wtr. Body'"r
Mill 1111111 on 111 Mw 09 a WE
OMEN [=MEN 0
MEMO Mill simammosiom
MMUME 0 1011010111MIEW-A 111111
.M.
No
MEMEM
M111MMMOOMMEMN
No
0=1110MMIMMEMEMEM
No
man
-:
CIA
mm
No
Q
a
U
0,
ME120
1111111]
I
NU7
1
ONE
%,
wqNL=11
10
Mimi
OMEN
ON
NEW
No
111
mom�mm�m
MEMO
No
Im
ANIL
ON
Elm
WW"10=16MME
MOMENO
MEN
WOMEN
m�mm�mm
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
Application Fee(s) Check #
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 I) 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
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/ 1-888ARCOAST
Location:
Fax: [phone]
2728 Capital Blvd.
(Serves: Carteret, Craven, Onslow -above
Raleigh, NC 27604
New River Inlet- and Pamlico Counties)
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)
Washington District
943 Washington Square Mail
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 08/09/06

J;JL- 1 6-2009
02:06 PM BROOKSDREDGING
2525044744
P.01
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFTIBOA.THOUSE)
ts
hereby certify that I own property adjacent to (Na0ttie 11 C � E EI �� \< _
of Property Owner)
property located at
(Lot, Block, Road, etc.)
on - � ��`�E in N.C.
V �o� � >
(Waterbody) (Town And/orCounty)
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 11ot wish to waive the setback requirement.
✓r I dQ wish to waive that setback requirement.
--------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
Si#lture
Print or Type Name
Telephone Number
Date;

JUL-16-2009
02:06 PM BROOKSDREDGING
2525044744
P.01
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFTIBOATHOUSE)
i. I hereby certify that I own property adjacent to 'll:iC CCKy' Wcaj:�--� is
(Nance of Property Owner)
property located at F-) -rn - -'a6
(Lot, Block, Road, etc.)
on (�X�,-�e� rc'g� in iC — 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 (I5') from my area
of riparian access unless waived by me.
I do liet wish to waive the setback requirement.
.� I dQ wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
--------------------------------------------------------------------------------------- ------------
Signature
--222r�
Print or Type me
Telephone Number
Date; �V-�

��e
-- --- ---- -i

Rankof America -*;o-
as
Date
Pay To Tfie
Order.:Of
Personai Money Order
No. 0751739
90-DAYS'
LD
JULY 17, 2000
"FOUR HUNDRED DOLLARS AND 00 CENTS
Not Valid Over $ 1000
Bank of America is not liable for lost or s �f�4ser(Draww)
stolen Money tor your 1?rotection
against loss or theft, sign and complete this Money Order as soonZ,—
as possible.
ame I lwcaaset Drawer)
Bank of Arnerica. N.A.
Son Ant T
bu I fl-� Address
$200200 00023 000751739 6,?inn- City, State, Zip
-?;0 repd,i-7 !��4331
0 7 S 17 3 9 111 1: 1140000 1 q 00 i r
• It at u u u h h k 110
0 THE ORIGINAL DOCUMENT HAS REFLECTIVE WATERMARK ON THE BACK
I N
THE ORIGINAL DOCUMENT HAS REFLECTIVE WATERMARK ON THE BACK 0

RCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor .lames H. Gregson, Director Dee Freeman, Secretary
Date
Applicant Name
,-k) \"�' (- v-" S
Mailing Address-�)7��1�C���7
JUL 2 0 2009
Morehead City DCM
I certify that I have authorized (agent) •-�r rNy�c o (e-jr0 to act on my
behalf, for the purpose of applying for and obtaining all LAMA Permits necessary to
install or construct (activity) I-)e
at (location) Uec C.)`pk r- 4 L l 20
This eertificatiop-is valid
Signature
(date) -� ' l � -2- 61
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
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