55338_JALOZYNSKI, JACKIE_20100414

❑ CAMA / ❑ DREDGE & FILL
GENERAL PERMIT ( Previous permit #
❑New ❑Modification ❑Complete Reissue LlPartial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Re 2.s
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
D Rules attached.
Applicant Name t ice- t
Address ?
City el ' 1 atej\L(— ZIP_
Phone # ( rf , + i Fax # ( ...
3`
Authorized Agent ,�"�(- , t I t
Affected ❑ CW O EW PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
AEC(s):
❑ PWS: C7FC:
ORW: yes / no PNA yes ,/'no7 Crit.Hab. yes /:'no
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision a -_
City ZIP
Phone # O River Basin
Adj. Wtr. Body (� (nat /man /unkn)
Closest Maj. Wtr. Body�
i
Type of Project/ Activity ; I ! <
i
(Scale:
Pier (dock) length
Platform(s)
Finge
Groin
Bulkhead/
Basin,
Boat
Boat
Beac
Other
Shor
SAV:
Sand
Moratorium:
Phot
Waiver Attached. yes no f
A building permit may be required by: iJ See note on back regarding River Basin rules.
Notes/ Special Conditions
r pier(s)
Agent or Applicant Printed Name. Permit0 icer's Si na re
Signature �� Please read compliance statement on back of permit!'f lssuinob ie. piratio
K
d
ApplicationFee(s) Check# Local PlanningJurisdiction RoverFilel

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 l) 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
Mailing Address:
1638 Mail Service Center
Raleigh, NC 27699-1638
Location:
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293
Fax: [phone]
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST
Fax: [phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico Counties)
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 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 08/09/06

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/V,(OOR -ING PILINGSBOATLIFTBOATHOITSE)
I hereby certify that I own property adjacent to �i < 1 /6 'ZYNs 's
(Name of Property Owner)
property located at //3 144.,r,,1 c- -�
(Lot, Block, Road, etc.)
on a ,d «_� in Y N �` rye & S�c I ,—F,7 - N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: b -973,5' Mailing Address: ) I S Qe-olye
RkS ' NG ai�7S�
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. (If you wish to waive the setback, you must initial the appropriate blank
below.)
I do not wish to waive
I do wish to waive that setback requirement.
------------------------------------------------------------------------------------------------------------
-----DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
/```'ro/e,,e
&A4 / i 'F - ; A�s Aa //Fc/
Yo, �
(Information for Property Owner Applying
for Permit)
) I s Ae-o eti �'-t
Mailing Address
t [(� s /V c
City/'State/Zip
`111-7L10-9735
Telephone Nu er
off. 3 2 7 Q
Si nue mate
-------------------------------------------------------
(Riparian Property Owner In ormation)
Signature
Qt l A'aq %rtP'I<eF-
Print or Type Name
-7a6- 37 3o
Telephone Number
3127/%a
Date
Din 5LL9 9ZL Z99 XVA

z
ADJACENT RIPARIAN PROPERTY OWNER STATEMENTT
(FOR A PIFR1,W00RLVG P11,1:NGS/BO,1 TLI�FFT/BOATHOL'SE)
I hereby certify that I own property adjacent to �(r c-o s •� s
(Name of Property Owner)
nrowtrty Iorateri %tj
(Lot, Block, Road, etc.)
on "U in _ //
�ai-E,5 N.C.
(Waterbody) (Town and/or County)
Applicant's phone #:
Mai -ling Address:
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. (If you wish to waive the setback, you must initial the appropriate blank
below.)
I do not wish to waive
I do wish to waive that setback requirement.
-----------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
;�,�
[^I//^ , - - m �/Emit 7—
6 f-`- A4
{jtis-f r�5
�= K
113
-------------------------------------------------------
(Information for Property Owner Applying
for Permit)
113 'A c.ac c,
Mailing Address
CitylStaie/Zip „
Telephone Numb
3
ig tre Date
--------------------------------------------------------
(Riparian Property Owner_ Information)
Signature
i�,Qrccs
T
rrint or Type Nail c;
Telephone Number
Date
Zoo12] 31UH SLL9 9ZL ZSZ xyd LZ:61 010Z/10/£o

WC D,+visien of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: Jackie Jalozynski
Date: April 14, 2010
General Permit #: 55338C
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
OW
Dredge ❑ Fill ❑ Both ❑ Other O
169
169
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
252-808-2808 :: 1-888-4RCOAST :: www.nccoastaimanagement.net revised:02/03/10

ERIC B. ELLIS
JASA M. ELLIS 4156
205 NOTTINGHAM LN. 252-726-6775
MOREHEAD CITY, NC 28557 c/ 66J0/531
133
Date
Pay to the ^ /
Order of /V �$ a0o,©�
o- o sd Dollars
Beck.
First Citizens
r Bank
firstcitizens.com
NP
I:0531003001:0013174487801I' 04156
b
ly