40379_PAGE, L.B._20050415

�CAMA / ❑ DREDGE & FILL
ENERAL PERMIT
Previous permit #
L lNew ❑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
C Rules attached.
Applicant Name_
Address
City
Phone # ( )
Authorized Agent
Affected ❑ CW
AEC(s): ❑ OEA
❑ PWS:
ORW: yes / no
State ZIP
Fax # ( )
❑ EW ❑ PTA C ES -1 PTS
❑ HHF ❑ IH J UBA I-: N/A
_I FC:
PNA yes / no Crit. Hab. 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 j
cubic yards
Boat ramp
I
t
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision
City - -
Phone # ( )
Adj. Wtr. Body
Closest Maj. Wtr. Body
ZIP
_ River Basin
(Scale:
(nat /man /unkn)
Boathouse/ Boatlift
I
Beach Bulldozing --
Other
Shoreline Length _
'r
gt I
I
SAM not sure yes no 1—
Sandbags: not sure yes no -
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no — -- ------ --- -
A building permit may be required by: / ( C See note on back regarding River Basin rules.
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
Officer's Signature
Issuing Date
Expiration Date
Application Fee(s)
Check # Local Planning) urisdiction
Rover File Name

It
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:
1 Tar - Pamlico River Basin Buffer Rules Other:
�_ _j 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

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS/ROATLIFT180ATHOUSE)
I hereby certify that I own property adjacent to `s
►^s i
write of Property Owner)
/0 7loka(f � 6 10a t- J 4P (P 3 / 502 76 Z 37 400,:�:D
property located at 1-60n SLLz t'I
(Lot, Block, Road, etc.)
on Ld P.lrt'1� , in Car —_�-- N.C,
'aterbody) (Town anti/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
PI11i11fUJl Lb 3%A tia-A A ni4iin) um diatancc of fift"n foot (15') from my arvw
of rinarian waived by me.
I do,= wish to waive the setback requirement
I lia wish to waive that setback requirement,
DESCRIPTION ANTDiOR DRAWING OF PROPOSED DEVELOPItitEitiT:
(To be filled in by individual proposing development)
Sign e
� ilLL E.r1 1 ea—,-Q 1
Print or Type Name
1�.5�2- g3-(0Z7
Telephone Number
Date: !,ZI 5,k s

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS180ATLH,7'1BOATHOUSE)
f hereby certify that I own property adjacent to s
L&7 Pearzsan Ctc. le (Maine of Property Owncr
property located at
(Lot, Block, Road, etc.)
on��� LC� _ �� in , 1� l, N, C,
aterbody) (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
PlIll l6a'UVAlllfu'UvaLlwux nivaL b4, a%,L UwA a m'oimunz diatancc of iiftcon foot (15') from my aroa
of rinar;an arrPcc lin'rt.cc waived by me.
I di1.,t7S2I wish to waive the setback requirement. t.
I du wish to waive that setback requirement,
DESCRIPTION ANDrOR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by iudiyidual proposing development)
--------------------------------------- ---------------------------------------------------------.......---------
Signature
D,0,11927q p , A
Print or Type Name
Telephone Number
Date: �J 115 /0

L B PAGE
JUNE PAGE
PH 252-393-8275
467 PEARSON CIRCLE
NEWPORT, NC 28570
PAY
THE
O ORDER OF
---
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DATE /J 66-30J531
342
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