Moffitt, George

' CAMA / ❑ DREDGE & FILL
GENERAL PERMIT Previous permit#
W-�t,4ew
A B C D
❑Modification El Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources S l
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
❑iRules attached.
Applicant Name `� -' .•� �.. : i ! L Project Location: County i
Address 1�-� t ,`ti i • 1 { l t. 4' 1 <f -r�' . �;^L� i J L (ZStreet Address/ State Road/ Lot #(s) i
. City.
State �ZIP
Phone # i)
! '11 t' `,Subdivision.
!`
E_Mail
tY• C
l
ZIP
AuthorizedAgent�
z
i
Affected ❑ CWIE'
PTA ❑ Es
❑ PTs 1 - ' t hone # ( )
��� '
River BasinC'�❑
OEA HHF
AEC(s):
H ❑ UBA
❑ N/A r p
Adj. Wtr. Body �' (nat %man /unkn)
❑ PWS:
\)
Closest Maj. Wtr. Body
ORW yes / (no PNA
yes /! r�
ti x
Agent or Applicant Printed Name
~' Signature Please read compliance statement on back of permit
ApplicationFee(s) Check# ./
Permit Officers Printed Name J i"
Signature
Issu ng ate I 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 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 howto complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888-411COAST
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

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
✓ rl
'I hereby certify that I own property adjacent to .C.tJz�(
(Name of Pro rty Ow�gr) ,
(AUMess,1-ot 1ocx, rcoa®, et -
on . in -�,� Agk��1 ti� ti, N.C.
(Waterbody) andior County)
The applicant has described to me, as shown -below, the development proposed at the above
locatio
1 have no objection to this proposal.
have objections to this proposal
DESCRIPTION ANDlOR DRAINING OF PROPOSED DEVELOPMENT
(individual proposing development gust rill in- description below or attach a site drawing)
_ l
51
WAIVERSECTION
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 walue the setback, you must initial the aprropdate blank below.)
d� 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)
Si tune rgnature i }� ��
Print or Typ6 Name Print or Type "N�me
Mai ' g ddress i M 7tn AddressG 1
City/$fate ' City/State/Zip
I� - /D�%� MAY ,1' 1 1015
Telepho Nu ber Telephone Number Pc';,�_,n war,
�, �
Dates ,— Date _
r o 3-of 5
�� ^ ! (Revised 6/18/2012).

j . 'id.1 11
% ..ADJACENT RIPARIAN PROPERTY OWNER S fATENIENT
I hereby certify that:/ own.property adjacent to b` 172,
(fme ofiPr Property Owner)
V P - —
(Address; Lot, Block, Roams etc•ji�L,
on inG;�iS
W t b d (CityfTown and/or County)
,s
( a er .o .Y)
The applicant has described to as shown below, the development proposed at the above
IocatiAr�
I have no objection to this proposal.
; Sim i a
WAIVER SECTION �
I understand that a pier, dock, mooring pilings, breakwater, boat�ouse, 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(/,} - ��q-rr�iv ,¢Mop<z
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent perty 0 er Information)
Ign tune t- Sign re
Print or Typ Name Print or Type Name
M' 'ng A dress �-Ma/fingAddress �.- �`,'"��r.-� i/2'.�J�ZRECEIVE
City/State2ip Cify/Stafe2ip ,
G 14 / r mac•-l-1r, 1 - • - -
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