Moncourtois, Rowena

❑DREDGE & FILL NV
EN ERAL PERM 1 Previous permit #
New ❑Modification ❑Complete Reis ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources 1
and the Coastal Resources Commission in an area of environmental concern pursuant to 1 SA NCAC ! UO
_ y _ ules attached.
Applicant Name .f� G./�'�H /f n C U yrt� it Project Location: County
Address
State IV( zip
Phone # (_) Fax # (_)
Authorized Agent �(✓1 r N �� 1
Affected aCW �W -ETA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ N ❑ UBA ❑ N/A
❑ PWS: ❑ FQ
ORW: yes /0b) PNA reds / no Crit.Hab. yes / no
Street Address/ State Road/ Lot #(s)
/6y (_'Adr 0,4t 51V8 Ae
Subdivision
City. S4,'lG zip d. 8'� 32.
Phone # ( ) River Basin Lt )4l i4, Op I
Adj. Wtr. Body c r / n ,j ` Y < fiat man unkn
Closest Maj. Wtr. Body , U.
Type of Project/ Activity 170 ,x 6 ' do c 1f
U 'x /9 / r7l' ro",-, (Scale:
Pier (dock)
Bulkhead/ Riprap len ti %
a, distance offs to
max distance offshore
Beach Bulldozing
_ .
Shoreline Length
`SAV: not sure
yes
no
Sandbags: not sure
yes
ono
Moratorium: n/a
yes
ono
;Photos:
yes
.w�i.,ar e�«��tio,�•
.,ems
..,,.
A building permit may be required by: �. C-'/ F'/ r ' - U ❑ See note on back regarding River Basin rules.
Notes/ Special Conditions ; ; , r I r A- i* V (-n (n � / � (� I ^ � C I

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, certifythat this 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 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 Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-8884RCOAST
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

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of P Owner Applying for Permit:
RECEtyFi
Mailing Address: MAR 2 5 2013
J
DCM-1 .11) CITY
e��,
I certify that I have authorized (agent) to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date)
Owner Signature
.nt iI
.W-21A ��
Date

AC
I hereby certify that I own property adjacent to
property located at
on
e
(Address, Lot, Bl ck, d, etc.)
in
(City/Town and/or County)
's
a8.s-7:2
N.C.
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 development must fill in description below or attach a site drawing)
�tECEIVED
oak I OR 2 5 2013
CITY
AIVER 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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Propoy Owner Information)
Print or Type Name
o
Mai dress
City/ ate/Zip
2s - 7:Z7- 3n A o
Telephope Nufnber
Date
Print,or Type
Information)
- 77-7 _ 3o6
Telephon Numb
Date
(Revised 6/1 &2012)

I hereby certify that I own property adjacent to
(Narreof
property located at
(Address, Lot, B oa
on , in
(Water dy) (City/T
I
ty Owner)
N.C.
nd/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 development must fill in description below or attach a site drawing)
1�
o1
TV
REC81VED
AAR 2 5 202
1)C, : `,�TO r111v
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.)
I do wish to waive the 15' setback requirement.
do not wish to waive the 15' setback requirement.
(Pro adE- Dwner Information)
Date
Zacent r rty n21nfoErat2ior
r
Signature
Print or Ty�Pe. Name p / ,rC P d
te
ss Mailin Add e�y
�G � 81- O o2
city,(S ip "3 r13 q
Telephone Number
Date
(Revised 6/18/2012)

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