Jackson, Eugene

4,GENERAL
/,ElDREDGE & FILL PERMIT Previous permit#New` ❑Modification ❑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 / /j L/
�[' r' E] Rules attached.
t...I r, (='i f � } �! C kil)--7, Pro ect Location: Coun
Applicant Namej County_
l
Address C. (/-%I (J `E (����/: �r.• t Oil Street Address/ State \Road/ Lot #(s) I /
ti �! J it i" !\ c-t
City ►�'+ I ( State �ZIP J7 1 _ Y
Phone # ( � �� -" E-Mail Subdivision
Authorized Agent City �- %fF-` ZIP ? �� ✓
Affected
❑ cw ,Q�w , 0-PTA pis ❑ PTS Phone # ( ) River Basin
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
AEC(s): Adj. Wtr. Body Ct i �_ ��+r� (at. /man /unkn)
El PWS: -1 --� -'
Closest Maj. Wtr. Body
ORW: (ie-i / )o PNA yes rho,
Type of Project/ Activity l�� e lll n 11 G� / C, ,-� �, 11 1A r,•
(Scale: /V S
Pier
Fixe
Floati
Fing
Groff
$ul
Basi
Boat
Boat
Beac
Oth
Shor
SAV
Mo
Phot
W'
�ii
�G�.i■i
ii�
�=ai
iiC�
u■
■■■
length
NONE
0
number
■eu
��ME:CMEMO
max distance offshore-
CC:C
cubic yards
ramp
i Bulldozing
r
"raw
M
in
ONE
NEEMENEM
MONEEMEMEN
A building permit may be required by: -t �`i r' = 1 / ("'( ❑ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction) + s
Notes/ Special Conditions
�r
Agent or Applicant Printed Name
' + /
Signatur * please read compliance statement on back of permit"
Appli&tion Fee(s) Check#
Permit Officer'sPn tid Dame !�
Signature
Issuing Dati E�tpiratidn 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 consistentwith 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 how to complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
Washington District
400 Commerce Ave
943 Washington Square Mall
Morehead City, NC 28557
Washington, NC 27889
252-808-2808/ 1-8884RCOAST
252-946-6481
Fax: [phone]
Fax: [phone]
(Serves: Carteret, Craven, Onslow -
(Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet- and Pamlico
Tyrrell and Washington Counties)
Counties)
Elizabeth Citv 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)
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

,i
AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying`;, for Permit:
Mailing address:
.? s-77
Telephone Number:1
certify that I have authorized (agent/contractor),
to act on my behalf, for the purpose of abiying and obtaining all CAMA permits
necessary for the proposed development of
at my property located at
This certification is valid through (date).
(Property Owner Information) -
Rtcevfo
0 61015
Title, co. owner or trustee for property
Date
Telephone Number
�-S W cP . C-
Email Addre s
RECEIVED
JUL 0 61015

lun 2415 06:22p Larry G. Arnoidl-a
2527263018 p.2
ADJACENT RIPARIAN PROPER-- OWN R STATE
I hereby certify that I own Property e adjacent toEMEMT
's
Property located at � o � C-- AI` tc L �me of Property Owner)
(Address, Lot Bloc(, Road, etc.)
e-rIA-AR h �' in
(Waterbody) N.C.
(city/ own andlor County)
The applicant has described to me, as shown below, the development proposed at the above
locafion. �
I have no objection to this proposal.
1 have objections to this proposal.
DESCRIPTION AND10R DRAWING OF PROPOSED DEVELOPMENT
(lrrdfvidual proposing development must fill in description below or attach a site drawing)
c') 5 ecl d3ul,ft 4eAd .�kAC-en2eK(`
WAIVER SECTIOm
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse,
must be set back a minimum distance of 15, from lift, or groin
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.
(Property Owner Inforrnatian)
(Adjacent Property Owner information)
Si nature
Si ature * -
Print or Type Name A� � I
(p 1 W E Pnnt or Type Name �V
M mq Address
1 T1.t ► �^ �� '[ C .1 Malii g ddress
C1fy/Sfa i5? a_
c►ty�1 temp
Telepho a umber/emailaddress
p,
Tel—p e umber/email address
RECEIVED
Da JUL 06 1015
n
*Valid for one calendar year after signature*
(Revised Aug. tom)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property;adjacent to F—�.h C., �.�% .� ZAc kso� s
(Name of Property Owner)
property located at L+03 C,�A ��L L 1s k;-.
(Mciress, Lot, Block, Ro , etc.)
R b &,%aA9P-1in S , N.C.
(Waterbody) I(City own and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing developmeni must rill in description below or attach a site drawing)
4 a""
3`( U'fY-�-'� 13'
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.
(Property Owner Information) (Adjacent Property Owner Information)
S'igna re Signature
�V.G N fz� Cy IC,inhOh
Print or Type Name Print or Type Name
�o' W 1Z�VE Stp � 4657 C6o,nne.l r-
Mailing Address Mailing Address
mc�►,i-ram.^ 51c . N (-
Ci /S at ip !IIP
tate/Z_ _
5Z—a1 ' '] 5 y 5 RECEIVED
Tel%67 N er/email ad Tess Telephone Number/email address
Date Date*pp,►M
(Revised Aug. 2014)
*Valid for one calendar year after signature*