43194_STANFORD, DAN_20051108

_I MA / `6REDGE & FI L / / �� %G! � >� ,/ 3194
GENERAL PERMIT `
Previous permit #
t-JNew L'Modification 1 Complete Reissue ❑Partial Reissue Date previous permitsued
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___Project Location: County___ _
Address — r}" /� Street Address/ State Road/ Lot #(s)_
City State 1 ZIP' —_
Phone # ( ) 1 ,' r. U 1 a Fax # (_) Subdivision
r -;-
Authorized Agent r.�l�a X,, 1�� City- 0 r ZIP .
CW -1 EW E PTA =7ES ❑ PTS Phone # (_) River Basin
Affected OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A;
AEC(s): Adj. Wtr. Body__ (nat man unkn
PWS: ❑FC:� -/
ORW: yes / no PNA yes / nu Crit. Hab. yes / no Closest Maj. Wtr. Body -�—
Type of Project/ Activity
Pier (dock) length
Platform(s)_
Finger pier(s) t
Groin length
number - --
Bulkhead/ Riprap length 't w
avg distance offshore '
max distance offshore
Basin, channel
cubic yards
Boat ramp
Boathouse/ Boatlift _
Beach Bulldozing
.r d
Other
I n
Shoreline Length
SAM 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
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
Application Fee(s) Check #
(Scale: / V - )
See note on back regarding River Basin rules.
Permit Officer's Signature
r r
Issuing Pate f
k,
Expiration Date
M�vt31T�
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 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:
L _I Tar - Pamlico River Basin Buffer Rules [_i Other:
__1 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/ I-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 06/29/05

UNITED`.�l:Jfid�QT,Atr=ttT>�tKva�sm:n<-•ac:..• •.< .. I
• Sender: Please print your name, address, and ZIP+4 in this box •
- L�1
C YI
C � �
IN111lf!lIIIll!!lIi,i�l��ie�l,fel�,l,lr=,!!
Z-ENDER: COMPLETE THIS SECTION
COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1, 2, and 3. Also complete
A.
Signature
❑Agent
item 4 if Restricted Delivery is desired.
X
_/
❑ Addressee
■ Print your name and address on the reverse
so that we can return the card to you.
6.
eceived by (Printed Name) C. Date of Delivery
■ Attach this card to the back of the mailpiece,
f-� _ ,-
or on the front if space permits.
D.
Is delivery dress different from item 1? ❑ Yes
1. Article Addressed to:
If YES, enjor dellye address beT6w: - O No
NOV 0 7 2005
3.
Service
11
❑ Certified Mall ❑ Repress Mail
��
[3 Registered ❑Return Receipt for Merchandise
0 Insured Mail ❑ C.O.D.
4.
Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7002 2 410 0002 1133 7647
(Transfer from service label,
102595-02-M-1540
PS Form 3811, February 2004 Domestic Return Receipt

CERTIFIED MAIL - RETLRN RECEIPT REQUESTED
DIVISION OF COAST -XL NLAr AGENIENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER
FORM
Name of individual applying for permit: DA tJ1Et- STA tiff .D
Address of property: 511 IV e ast 4.
(lot or street #, street or road)
r/a pAA
(City
I hereby certify that I own property adjacent to the above referenced property. The
individual applying for this permit has described to me (as shown on the attached
drawing) the development they are proposing. A description or drawing, with
dimensions, should be provided with this letter.
V I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coastal
Management, 400 Commerce Ave., Morehead City, NC 28557 or call [phone]
within 10 days of receipt of this notice. No response is considered the same as no
objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift or sandbags
must be set back a minimum distance of 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.)
�� &TV
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
lVt2'�rr�- W//
Signature Vate
Print Name
Telephone Number With Area Code
Geoffre� T f�y�7�efjf

DANIEL STANFORD
LIZA WIELAND
P O BOX 158
ARAPAHOE, NC 28510
Pay to the
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Date / 472
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$00 BANK Rrsr Cdizcns Bank B Trusl Company
On,t C,t, N s 28571
www.firstcitizens.com J ! y
For
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