Gentry, William

4,7
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MA/ XDREDGE & FILL":
ENERA L PERMIT Previous permit #
ew T]'Modificaiion ElComplete Reissue ElPartial Reissu Date previous permit issued
As authorized by the State of North Carolina, Department of Environment ahfd Natural Resources
-114 -r�)4�()o
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
0 Rules attach6d.
FApplic;antName_:::1J)(L4-T_) C-kA_)4AA-- Project Location: Countyftt. vl(yl,
Address Street Address/ State Road/ Lot #(S)
I/CU I
City State P
Phone # # SubdiviiMiq ---------------
City.
ZIP
Affected I ECW PTA EES EPTS Phone AJ,:,r 1'VVRiver Basin l_K/ 0 OEA [I HHV 01H EJ UBA El N/A
AEC(s): Adj. Wtr. Body
11 V
LFC:
ORW: yes / PNA yes / no Crit.Hab. yes no Closest Maj. Wtr. Body—
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{Age or Applicant Printed Name P f
Pleas back of permit
Signature e read compliance statement on b Iss in
' I LlPlnniniurisdiction Rover File Check#
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Statement of Compliance and Consistency
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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 Headauarters
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

0
C
Applicant:
Date:
V�
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.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)_amount
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
252-303-2303 :: 1-888-41RCOAST :: vj w*.v.naccoastaimanogamero?.net revised: 02/03/10

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date 3
Name of Property Owner Applying for Permit:
Mailing Address:
1D J -12N0y 13J`7
94�,,-T,11 � \J,A } 24S*43
�C1rlY�i�
AUG 16 2013
DCM MIID CTIy
I certify that I have authorized (agent) 01 i,-p i Q-LJ'C-� 1w5 to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) 1 S k— "5 5 ff) yV L
at (my property located at) 2 �� Z 1-4c-�-gN o1,e-_ jZ
This certification is valid thru (date)
i Z/
Property Owner Signature
3. '5 .
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby ceriify than I own property adjacen to v? ! I t r� +�, �`e r,-, 4 z. 's
(Marna of Property 03 Ifler)
property located at 2� �.. Z' L _ �I plocy"JI 1 ) C
(Addrssa, Lot, Biock, Road eic•)
or3_
(fiaterbody) - (Cityffo r andilor County)
Pie appl, ant has desonbod to me, as i'io"Ov.", that it a'dd op rule- , it proipo;scd ill til) a i :vT
locatio .
R$ 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)
40 Li
ti o
i�roP+s-4 Moor ^
_ mo \.E .0 I,.rs�<keVj
loft 'SON �'DRe�nGCF--Q�h,rv1�
WAIVER SECTION
understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin musfWD
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.) AUG 16 203
I do wish to waive the 15' setback requirement.
I do not wish *to waive the 15' setback requirement.
(Property, wn Inf ,rmati0h)
IV �-
Signaiur`e
Print or�Tyype Name
�.� . `tJaX 1 o3ocj
Mailing Address
City/State2i
Telephone Number
-3- 30 13
DCM--MHD CITY
(Adjacent Property OwnerAnformation)
Print or Type Name S ��
a" 2 LY)
Ving
d rb S
v J:v G
City/State2ip2. � S--S -7
Telephone Number
9 t f -1C �ID9-`f-�
Date
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to LJ I H i n M G---Yx 4r, is
(Na a of Property Owner)
property located at Z 2 LES 4rto-1-`,j 1 I Ic 1 �p
(Address, Lot Block, Road, etc.)
oin jg -'�.,zT^ , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
Z"Q- a ,,, 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 in description below or attach a site drawing)!!
IE-/,4,N --, L,',�+
0
A*s14tl
pro PQ'JL , �n-5 'To i'.L
'per GF'����:�
`R�5'g,,►a.T'
)�x3
WAIVER SECTION
understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groiFi fMe set
back a minimum distance of 15' from my area of riparian access unless waived by me. (If ou
wish to give the setback, you must initial the appropriate blank below.) M
Auq
I do wish to waive the 15' setback requirement.
.CMr clay
�
1 do not wish to waive the 15' setback requirement.
(ProgertyrOwnek,lnforr ation) (Aoiaoht,Prqpgrty Owner Information)
Signature
Print or Type Name
? a t3a•f ) 073C>5
Mailing Address
04r,'-" Ile V iN 7-15�13
CR State/Zi
�03 1ZJ�
Telephone Number
Print or Type Name 2
115�1 I U S 14,
Mailing Ad ress
c L, 44 h A. V
Q VStatpMp W 4?`J 5*
Telephone Number
I-')3 -)-->,
Date
Date
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