Conway, Mark

CAMA El DREDGE & FILL
'T us
WGENERAL PERMIT Previopermit # A 11 C D
Q]New DModification ElComplete Reissue El Partial Reissue Date previous perrr�it 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
Rules attached.
Project Location: County
Applicant Name —
Address Street Address/ State Road/Lot #(s)
City State zip
E-Mail
Phone # Subdivision,
7
--.
Authorized Agent city ZIP t le
PTS ES River Basin w ql�w PTA: El El Phone #
Affected 0 CYl ' 0 HHF 0V
0 O0 UBA 0 K/A EA 11H
AEC(s): 0 PYVS:
01RW: Yes /no i PNA yes /(Po,.'
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s)
Floating Platform(s) to I
Finger pier(s)_.��..
Groin length
number
Bulkhead/ Piprap length
avg distance offshore --
max distance offshore
Basin, channel
cubic yards ---
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
e'-�
Other
ShorelineLength(j'_
SAV. not sure yes
Moratorium: n/a yes P9 J
Photos: yes no'
Waiver Attached: yes no
A building permit may be required by:
Note Local Planning jurisdiction)
Notes/ Special Conditions
0
-A
Adj. Yvtr. BodyInat UP LunKn
Closest Maj. Wtr. Body —
(Scale:
as
El See note on back regarding River Basin rules.
f
A
g Applicant Printed Name
Agent pr
PermitOfficer's Printed Nirne;
1V411wV f,/ I
S. 'Pleas
ignat6re #4 read compliance statement on
back of permit
Signature i
i
Application Fee(s) Check # Issuing Date' Expiration Date'

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, certifythat this project is consistent with the North Carolina Coastal Management Prog, am.
River Basin Rules Applicable To Your Project:
❑ Tar- Pamlico River Basin Buffer Rules
❑ Neuse River Basin Buffer Rules
❑ Other:
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 Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-648 1 ) or the
Wilmington Regional Office (910-796-7215) for more information on how to complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-8884RCOAST
Fax: [phone]
(Serves: Carteret, Craven, Onslow -
North of 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 Hall
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 - South of New River Inlet -
and Pender Counties)
http://www.nccoastalmanagement.net/
Revised 08/27/ 14

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
I in for Permit: C
O
Name of Property Owner App y g
Mailing address:.
Telephone Number:
I certify that I have author
ized (agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed de a ment of
fv c
at my property located at
This ce
rtification is valid through ' ate ).
(Property Owne
Title, co. owner or trustee for property
Date
Telephone Number
Email Address
RECEIVED
is it's
RECEIVED
JUL 2 1 �015
.:p Qli)F

A,,
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacentio
qn - s
property located at �! �% � I (Name of Property Owner
(Address, Lot�, �B+ock Roa , etc.)
on , in GiK-' ag -0-4/
(Wat body) N.C.
(City/Town and/or County)
The applicant has described to me', as shown below, the development proposed at the above
to tion.
F. I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must rill in1w
de cription below or ttach a site drawing)
-.
X 141d
RECENED
Q
j(ts 7'
/5Xir1,
JUL 1 10fi
N,�,, UU"M' ,,,VU,,,,y pn,ngs,►ooat ramp,ibreakwater, boathouse, lift, or groin
t be set back a minimum distance of 15' from my area of riparian access unless waived by
(If you wish to waive the setback, you must initial the appropriate blank below.)
�._ I do wish to waive the -15' setback requirement.
I do not wish to waive`tfie i5~setback requirement.
(Property Owner Information)
Signature
Print or Type Name
Mailing Address
City/State/ p
Telephone Number/email address
Date
t
*Valid for one calendar year after signature*
(Adjacent Property wn Info ation) RECEIVED
JUL 21205
�I hh0 wt,&-,r
Pjq or TypeNamp h
/email address
(Revised Aug. 2014)

�1
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
s
property located at 0 (Na a of Propert Owner)
ddress, L'�.G �kRad, et°nin G�ater dy) , N.C.
(City/Town and/or County)
The tv V
ant has described to me', as shown below, the development proposed at the above
IraI have noobjection tG�
o this proposal.�1���.
1 have objections to this proposal.
DESCRIPTION AND/OR DRAINING OF PROPOSED DEVELOPMENT
(individual proposin developm' ` f must gMi In description below or attach a site drawing)
y
CS f tri.
�zr�f
RECEIVED
I u derstand that a pier, dock, oring pilings, boat ramp, breakwater, boa ouse, lift,- or groin
mu t be set back a minimum distance of 15' from my area of riparian acce s unless waived by
m (If you w' h to waive the setback, you must initial the appr hate blan elow.)_
1 do wish to waive the 15' setback requirement `
I do not wish to waive the 15' ack requirement s t' ovs
(Property Owner Information)
T%hone Number/email address
Date
*Valid for one calendar year after signature*
(Adjacent Property Owner Information)
Print or Type Name (
1 �?C, �� �r`D��Ut3Cc�
xM to ddre .
ti _G
xCtty/Stateop
a N_ -�I3--gd-�y
Telephone Number/email address
Date*
(Revised Aug. 2014)