Ellington, Ed

O CAMA / ❑DREDGE & FILL
( I I l �✓ rr"rt " ,✓ tv cs . st c. A B ( C D
GENERAL PERMIT Previous permit#
QEJNew ❑Modification El 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 f�I 7 i• 6,
` [n `ales attached.
Applicant Name Project Location: County_Y
Address Street Address/ State Road/ Lot #e (s)
City. �, , ' / / '" State ,C� ZIP
Phone # /.: . +'i a E-Mail
Authorized Agent
Affected ❑ cw `,oEw '❑ PTA ElES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ WA
❑ PWS:
ORW: yes `/ no) PNA yes /'no;
r y
Type of Project/ Activity
!
Subdivision
City ( r r t.� ZIP
Phone # ( ) River Basin
t� ,y
Adj. Wtr. Body 1� j ' = r" t-•. (nat /man /unkn)
Closest Maj. Wtr. Body
J
(Scale: -/L/ )
w■
Groin length
number
Bulkhead/ Riprap length
ayg distance offshore
max distance offshore
■
-
Basin, channel
MEMEMEMEME
ME
cubic yards
Boat ramp
ON
MMM
Boathouse/ Boatlift
Beach Bulldozing
Other
CMM
C
C
Co�■�
�:��
Shoreline Length
SAV- not sure yes (no
Moratorium: n/a yes
Photos: yes
MEN
SON
ME
MOME
ME
A building permit may be required by:� ❑ See note on back regarding River Basin rules.
( Note Local Planning Jurisdiction.}
Notes/ Special Conditions
Agent or Applican Printed -Name
Signature' "Please read compliance statement onbzckQfpermit
'�*
rZ
Application Fee(s) Check #
Permit Officer's PFinted Name j
Signature
i( c..
Issuing Date E piratio 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 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 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 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 howto complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888ARCOAST
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.nccoastaimanagement.nett
Revised 08/27/ 14

From:Mark Ellington FaxID:SIA Group
03/17/2015 12:16 2523938280
DJACIEt
Page 1 of 2
THE UPS STORE 3942
I hereby certify that.I own pmparty adjacent t�
on -- (2- � � ,� ttAddres _
f. Se s aD in
' (Wat9rbody)
The applicant has descred to me, as shown
location.
I have no objection to this propla
have oblactions to this orooasa
DE3CRIPTIQN'AN1D10R DRAWI C
.(Individual propasingr deveiopmed mint ,ll 1,
S � �• � ► RCI� i:�D s N ��.� •
i
Date:7/8/2015 01:36 PM Page:1 of 2
PAGE 01/02
EIS a en
(Name of Property Owner)
llVIP61AT .-. .N.C.
(City/Town andfor County)
Blow, the development proposed at the above
I.AS L o it c A S A L L o id E R 1. [CAI- Arq ajer /y wnr—
OF PROPOSED DEVELOPMENT
descriptfon below or attach a site drawing)
. WAtVER.SECTi.ON • '
I understand that a pier, dock, moorinq pilings.'4reakWater, boathouse, lift, or groin must be set
back a minimum distance of 15' from my area f riparian access unless waived by me. (If you
wish to waive the sefbsck, you must initial the 1ppropriate blank below.)
V ' I do wish tv waive the 15' setback r uirement PECRVED
I dd not wish to waive the 15' setb�lck requirement. JUL d 6. 2015
(Properly Owner Information) (Adjacent. Property Owner Information)
Q i N�,
Sign s t Si RECEIVED
..il l,J.�� ►� �LC..c+S(o t� of 3Aritas � Ci2Cs5
Print or Type Name Print or T e Name JUL 13 2015
1,2T EtrW 5-r I 164 W�y.N1.ST. 4)da3. PQM-m
h9aflm Rddress M pin Add
'Mot 6
<(1 ' A 9bm .1)
s-1 asI /hviq
Cit /State/Zip
�d3 - 0
Tsfephone Number
! in li�� l� •
—
(Revised d18/10i2) -

11

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to d (,va EJ�lhcht,\ 's
(Name of Pr o erty Owner)
property located at I'M JqS h �31-
(Address, Lot, Block, Road, etc.)
on c�a , in _�,ffJAu4 Plot, N.C.
(Waterbody) I (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
_ I '.ff I have no objection to this proposal.,
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
RECENED
pL 131015
(Property Owner Information) (Adjacent Property Owner Informati n '`
90
aum
Si nature
�dwo,e d1;tn ✓f
Print or Type Name
tal OK14 2 -
Mailing Address t�
51 JDLASbDCO ae ai
City/State/Zip
a .3g3-21240
Telephone Number/email address
Date
�� � �, �f ��� lam► . �
Signature
5
Print or T pe Name
Mailing Address
�qWAri s leap o IISG a 9 shy pSctNEd
City/State/Zip
— 323 - JUL p 7 1015
Telephone Number/email address ,r
Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature*
i

I