58397_BROTHERS, JIM_20110906

❑(:AMA / ❑ DREDGE & FILL
GENERAL PERMIT Previous permit#
❑New ❑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
(( O Rules attached.
Applicant Name v G',.. Project Location: County
Address_ Street Address/ State Road/ Lot #(s)
City State "i ZIP
Phone # (,) Fax # O"`� Subdivision
Authorized Agent
Affected ❑ Cw ❑ Ew ❑ PTA
AEC(s): ❑ OEA ❑ HHF ❑ IH
❑ PWS: ❑FC:
ORW: yes / no PNA yes / no
riC City ZIP
❑ ES ❑ PTS Phone # () River Basin
❑ UBA ❑ N/A
Adj. Wtr. Body (nat /man /unkn)
Crit.Hab. yes / no Closest Maj. Wtr. Body
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Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
PermitOfficer's Signature ; l�
Issuing Date Expiration Date
Application Fee(s) Check # 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:
❑ 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

--. MN-
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date q-- f -- l I
Applicant lame
Mailing Address
Z-a
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I certify that I have authorized (agent&, w � � to act on my
behalf, for the purpose of applying for and obtaining all LAMA Permits necessary to
install or construct (activity)
at (Iocation)
This certificatio
Signatu
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] FAX: [phone] Internet: www,nccoastalmanagement.net
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled \ 10% Post Consumer Paper

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereb;i cerd :y that I own property adjacent to SJ ko�
Jame of Prop wty Owner).
L� Lproperty located it � C, O- , 0l � -ge kk c
t, Block, Road, te.) J
on o� .30 ✓
—" 'n -"C)_ff � f �I ; N.C.
(V",i iterbody) (T :1wn and/or Ci m )
Applicant's photre # , � `�o _ OMailing Add "esKh—n-T/Ti",
2GK (r S
He has described tc one, as shown below, the development ;.e is proposinl; at that location, and, I
have .no objections o his proposal_
DESCR 11TION AND/OR DR) i WING OF PRC POSED DEVELOPMENT:
1 o be filled in by pro,; erty owner prop. , ring development)
(Information For Pi o perty Owner Appl, ,i rig
for Permit)
Mailing Address
City/State/Zip
S V a � f-6 e j- 7 Y
Telephone Number
Signature
D, tti:
(Ripariai '`roperty Owner Information)
/v� 14::
�Signature
Print or 'Type Name
Z SZ _ Z3o—Z-3( ,-)
Telephone Number
Date

ADJACENT RIPARIAP PROPERTY OWNiR STATEMENT
I hereb:r cerd .y that I own property adjacent to by
. kkc ,S
� 'lame of Prop erty Owner)
property loc:►ted .ri � D Ci G.,�_
4, Block, Road, te.)
on _ �� 5U UJin fj-"o1 _L S5
(V's terbody) ' ` (T :1wn and/or Ct i nty)
Applicant's photrc #: �' �JJ (�_ ailing Add
ess: cam,
�a "�' � �Ne I s� • ��5
He has described w ine, as shown below, the development ;.e is proposing; at that location, and, I
have no object:ions .) his proposal.
DESCRIP B TON AND/OR DR) ► VYING OF PRU (POSED DEV ELOPWNT:
1 o be filled in by pro,) eriy owner prop ring development)
(Information For 111 o perty Owner Appl.-i rig
for Permit)
Mailing Address ,J ,,,
K�o Il S ha7� gels
City/State/Zip
(Ripariai Own Infotio)
t- -
2 Signature
Print or Type Name
`✓ r Telephone Number
Date

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