Gallants Landing Owners Assoc.

I�CAMA /XDREDGE & FILL
GENERAL PERMIT
A B D
Previous permit #
A4ew ElModification DComplete Reissue ElPartial
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 enviTonmental concern pursuant to 15A NCAC
Applicant Nam LAL
role nty
P ct ILocatiol: Cou
Rules attached.
e
Address
Street Address/ State Road/ Lot #(s)
State ZIP i
City. 7
Phone # 11i --A-Mail
Subdivision
Authorized Agent
City
ZIP
0 Cw El EW El PTA DES 0 PTS
Phone#
ikiveriBasin.
Affected
0 OEA El HHIF OIH 0 UBA El N/A
AEC(s):
Adj. Wtr. Bocly—L�—
1� I , —
A (nat iman /unkn)
0 PWS:
01RW: - I PNA
Closest Maj. Wtr. Body —
yes0 io,-., yes �o
Type of Project/ Activity
Pier
Fixes
Flow
Fing4
Groff
Bulk
Basir
Boat
Boat
Beac
Otho
Shor
SAV
Mor
Phoi
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cub! yards
WN
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MENOMONEE
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torium: n/a yes
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A building permit may be required by:
Note Local Planning Jurisclictio (I V /
Notes/ Special Conditions i ,
E]See note on back regarding River Basin rules.
'i J
v 4,
Agent or Applicant Printed Name PermitOfficer's Printed Name
n A
Signature "Please read compliance statement on back of permit" Signature
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 [)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
❑ 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 howto complywith 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.nccoastaimanagement.net/
Revised 08/27/ 14

Applicarit:
S
Date:
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Name
•
DISTURB TYPE
Choose One
TOTAL.Sq. Ft.
(Applied for.
Disturbanoe•total
'includes any
anticipated
restoration or
teMD im acts)
FINAL Sq. Ft.
(Anticipated•final
disturbance.
Excludes any
restoration
and/ortemp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
redg4 Fill ❑. Both ❑ Other ❑
CAM A
-
Dredge. [Fill•0 Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
-
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both' ❑ Other ❑
Dredge ❑ Fill ❑ _ Both ❑ Other ❑
Dredge ❑ .Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑ .
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ . Fill ❑ Both ❑ Other
Dredge ❑. Fill ❑ Both ❑ Other ❑
REcovf
IAN�'�1015 •

ADJACENT RIPARIAN PROPERTY OWNER STAddleff
EMENT
certify that, own property adjacent to � h GaH1�� kooAIAKS
hereby y p p Y J
3 (Name of P operty Owner)
.proportylacate�J_�t U"2 fK ff _�qA� , i1�L✓tfr��_r
Address, Lot B !c, oad, etc.)
(
on �r f'i n �s C�2�a a in &-a � 2y, � �c �ur�? �i— I.C.
(Waterbody) (City/Town andlor County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must rill in description below or attach a site drawing)
RECEIVED
JAN 21 1015
DCM-MHD CITY
RECEIVED
JAN .5
. C �oar
100 WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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.) RECEIVED
I do Wish to waive the 15' setback requirement. JAN 27 201g
I do not wish to waive the 15' setback requirement. f_t; Iprs Z!mr
(Prop rty Owner Information) (Adjacent Property Owner Information)
C
Signature Si ature
��lc /1.�,©�2P^e : �i�s . u�►!e Gas / e yi k,
Print or T e N me Prin fa,Type Name /
7i , '/� N i/il 1 D W N
M ' 1✓ e2� A ess
ing AddressMa 1
^,p
a yc 3 d
City/StatelZ' City/W;Z�.f
/Zi
Telephone Number Telephone Number
fWLe S�,my
! /lr
Date ate
(Revised 6110012)

' OAUJ6�l.Cld 1 i�IP'HI��KV rRvr�r� � i vnn�nc=.., • •-• • •...-.—.. .
I hereby certify that. I own property adjacent to
Gw I�ad� �� , �A �(� PS �iCC t��;�i✓ ,s
/) Name o Psoperty Owner)
...... ' PV
- Ct-C
(Address, Lot, B ock"pd,.)on U i7?1" , in a COJ�i , N.C.
(Waterbody) (City/Town andlor Coun )
The applicant has described to me, as shown below, the development proposed at the above
location.i
�l I have no objection to this proposal.
have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in description below or attach a site drawing)
. P �
. w
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set.
back a minimum distance of 15' from my areaof riparian access unless waived by me. (If you
wish to waive the setback, you must initial the appropriate blank below.) RECENED
do wish to waive the 15' setback requirement. JAN 2 71015
do not wish to waive the 15' setback requirement.
(Props ift O ner Information)
(Adjacent Property Owner I formation)
Ild /)�f
Si` ature
Si_ gnatC
re. s .
Print or Ty e N e
Q
Prip tor[ypName
1 S f
Mailing Address
Mailing Addrg �sssr� A/ 2 g S74
CitylStatelZip
Y
City/St tgelzip
`J
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Telep a m er
Telephone Number
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Date
(Revised 61I M012)

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