Dean, Roger

'1-11,�,C_AM'A El DREDGE & FILL
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GENERAL F!F.RMIT Previous permit Irp -I CC)
ew ElModification Pcomplete Reissue OPartial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources 7F 7
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC I'T-1 J 1.
es attached.
Applicant Name Project Location: County
Address— i; V
Street Address/ State Road/ Lot #(s)
city
e ZIP State
Phone #
LYE: -Mail Subdivision
( ) ii — T
Authorized Agent City, ZIP
ITA OES El PTS River Basin
Affected ❑!41
0 Cw w Phone # �k
0 OEA 0 HHF 1" 0 UBA 0 N/A
AEC(s): Adj. Wtr. Body— cc -fInat /man /unkn)
G•PWS: `_
Closest Maj. Wtr. Body
ORW(les)/ fil 0 PNA yes (nq 1
Type of Project/ Activity,.
Pier
Fixe
Float
Fing
Groff
Bul
Basil
B:::B
Beac
Oth -
Shor!
SA
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o Pho')
wall
(Scale:
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line Length
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torlum: n/a yes
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AtAtmdWA. 10.,
A building permit may be required by:
Note Local Planning Jurisdiction)
Notes/ Special. Conditions
Agent or Applicant Printed Name -
Signat Please read compliance statement on back of permit"
u(
Application'Fee (q­-7— Check#
�J See note on
,I M."
PermitOfficer's Printed Name;'
Signature
ssuiniDite"
regarding River Basin rules.
J
E

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, certifythatthis project is consistentwith the North Carolina Coastal Management Program.
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 (252-946-6481) or the
Wilmington Regional Office (910-796-7215) for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST
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 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 - South of New River Inlet -
and Pender Counties)
http://www.nccoastalmanagement.net/
Revised 08/27/14

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit:
Mailing address:
Telephone Number: .
9
I certify that I have authorized jl-ldl-fil kf>006: ' a ent/contractor
(9 ),
to act on my behalf, for the purpose of applying and obtaining all CAMA ermits
necessary for the proposed development of
at my property located at 6,33 1l.00f "01-c j> rt ✓--c
This certification is valid through �'' 3 % (date).
(Property Owner Information)
Signature
o G >E C. b G q,cJ
Print or Type Name
0G•"A -e e—
Title, co. owner or trustee for property
•+I� 2 r' �` RECEIVED
f 7 Date/ jUL 14 1015
4 3 -3 - 1 57 ,.
TelepKone Number
4-�-ece5e-r If2!(�2S/g 41)0 Coot,(
Ema' Address

QTr
r �x�Ttt�t�n ttllAiL • R�Tr•F;fPT RQUE�.
- - _ pJVIS1QN OF COASTAL MANAGEMENT .
ADJACENT RIPARIAN PROPERTY OWNER NOT
AD
Name
Name of Property Owner:!?4—'r
n-ZAN
A&
Address of Property: �' "' ' ' & Cddn
(Lot or Street #. Street or Road. City ty
Mailing Address: 33 �Jv
AppliCeAt phone #: �6 :, C.. Z�5g9„
'��--- - to the above The individual
I hereby certify that i own property d adjacentme >as shown o the tta had drravdng tho development
applying for this peiirit has describe uerov ded w th t la.
they are proposing. ar t on or aw �,:.51�..---
have no ot? cctlow to this proponl. 111avo objections to this propogd-
coas
lfy
ou have objections to what Is being proposed, you mus#notlfythe Division of nfor CH olf cos Is
pCM In writing within 40 days of receipt of this no�cm.htmnor�bY fcamngo f"888 4RCOAST. sNa
avail ble at www.nccoasta/mangemerttnet/aontact t —
• . - I-" aC nn A coon if you_have been notified b Certified Mai►
WAIVER 51=C7tON
1 understand that a pier. dock, mooring pilings, breakwater, boathouse. or lift must be set back a
minimum distance of 15` from Iny Brea of riparian 000088 unless waived by me. (If you wish to
m Ill the appropriate blank below-) RECEIVED
waive the setback, You Mugu it] RECEIVED
_ 1 do wish to waive the I& setback requirement. NOV or, to OCT 2 8 2014
I do not wish to waive the 15' setback requkGmen n LARU O"'y pCM-MHD C1iY
(Property Owner Information)
O signaltn'4
• _
print of Type Name
Mailing Addrass
City/state/Zip
\ Telephone Ngmber
n-O-
-
(Riparian Property Owner Information)
Sigy�rrtiare , .
REC:t,v«,
_� ...L. JU 1�'LO1�ii
date

4
SENDER: COMPLETEi
1 ■ ;Complete i#sins 1, 2, and 3 Also complete �' �,
A Stgriatu
C1Agent
}
3item 4 if Restricted.Delivery,is'desired
❑Addressee
n. Print your,name c rid address on,the reverser
so that we can return the card to you
I
Fieoetved f Printed -It.
Date Delive,�j
le ;Attach this card to the back of the mailpiece,
a'
I ,0 2
t or on the front if"space permits
p eliverq address diffe►ettt from Item i Des
1 `Article Addressed to
tf,YES; enter delivery address belowo
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2 ArttcteNumber." .." 7013 1090 DUDQ "3203' 9965
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Form 3811, February 2004; Domestic ReWrn Receipt oxsss oz nn tsao
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