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GENERAL PERMIT Previous permit#
L`lew ❑Modification ❑Complete Reissue Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources j� %� )�
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC / /
n :b J - , f fSRules attached.
4pplicant Name t f1 L !r 7 Project Location: County t_'-
p
Address ! s Street Address/ State Rd/Lot ISCi � � c rn' State0 ZIP St 7�-1 ! � f"�i;
I
Phone # CL1 a e i Fax # (_) Subdivision
Authorized Agent , q ; t y /1,Cc�f r g City C . r- : ci l� �� l ZIP
Affected ❑ CW '�3 EW nfTA MES ❑ PTS
AEC(s): OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑FQ
ORW: yes / f n 1 PNA yes / ifio j Crit.Hab. yes / no
t Type of Project/ Activity
Pier
Platt
Fing
Groi
Basii
Boa,
Boa,
Bea(
Oth,
Shot
SAV
Sanc
z Mor
Phoi
Wai,
L
Phone # ( ) Riv r Basin
r Adj. Wtr. Body f.4- +</ �!� lv '64 (nat man) unkn
Closest Maj. Wtr. Body f"�•J ', ` C� r.
(Scale: 60
)
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■
w pier(s)
length
i
number
■■■■■■■■■■■■■■■■■■■®■■■■■■■■■®■■■■■■s
stance offshore
max distance offshore
�■Y�a�ca■�lu
iYii
Y!Y■■■■e■■■■■■■■■■
cubic yards■■■■
■■f�■Y�Y■,3iY!EI■■■■■Y�
■■■■■■■■■■■■■■
ramp
■
■■■
■■■■■
■■■■■■■■■■0■■■�■■/ilu■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■�■■■w■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■�■■■�u■■fit■■�■■■■■■■■
:i Bulldozing
■■■■
Y■■■■■■■■■■■■■■■■a■'1■■�
nG�JY■■■■■■
■■■I�■■■■■■■■■■■■■■■�®i■■■�®■■■■■■■
■■■■■f�■■■■�it�■■■7IJ■Till
■■■■►/�!■■■■■■■■■■■■■
P�
■■
fline Lengthi'a�■■■i■■i■■aeiu■■■�■■■■■■■■
■■■■■■■JOIN■c■i■■■■■■■■■■■■
not sure: yes
■■■■■/■■■■■■■■■■■■■®■%��Y■■■■■■■■■■■■■■MEMMEMEMEMEMEM
A building permit may be required by: 7j El See note on back regarding River Basin rules.
Notes(/` Special Conditions "el 4d , t, !r ! � -- , `�.� j 1(C r •• r `-1' / "� ' ! / (.� �. �'r `• J� �
Application Fee(s) Check # Local Planning Jurisdiction Rover File Name
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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
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 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:919-733-1495
Morehead City Headauarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888ARCOAST
Fax: 252-247-3330
(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:252-264-3723
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Washington District
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Fax: 252-948-0478
(Serves: Beaufort, Bertie, Hertford, Hyde,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext.
Wilmington, NC 28405-3845
910-796-7215
Fax: 910-395-3964
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
Revised 08/09/06
Aff N =- WA
AN, j rA
RCIDEHR
North Carolina Department of Environment and Natural Resources
Division of coastal Management
Pat McCrory Braxton C, Davis Johr, E. Skvarla, ill
Governor Director Secretary
Applicant Names
Mailing Address e�K$e
I certify that I have authorized (agent r /Zt-j „/e��. ;� ( ate to act on my behalf, for the
purpose of applying for and obtaining all CAMA Permits necessary to install or construct (activity)
It/
This
Signature
thru
-241r 3
400 Commerce Ave., Morehead City, NC 28557
Phone:'252-8W2808 %FAX: 252-241-3330 Internet: www.nocowlalmanagamt.net
M Equa► Oppvku* %AflynwNe Allan Employer
at (location)
No ffiCarolina
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ADJACENT RIPARIAN RO ERTY O NER STATEMENT
I hereby certify that I own property adjacent to
Property located at / (ame of Property Owner) .s
gn (Address, Lot,81pck, Road, etc.)
(Waterbody}, in ,
(Clty/Town and/or County) ' N.C.
The applicant has described to me, as shown below, the development proposed at the above
loc ti
. I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPME
(Individual proposing development must fill In descriNTpt/on below or attach a site drawing
aA&Z, U-L• '7
lO�ix
WAIVERS CTION
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.
(Property Owner -information) (Adjacent Prope near Information)
err C)
or Type Name
Telephone Nu 7111
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Date If
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Wang
T Pe Name
Ad ess
Cliy/S to !p , J
40
Telep one Num e
�1 1
Date
(Revised 6/9812om
6 'd ES9Z 'ON hd66:Zl EM 'Ll '^ON
ADJACENT RIPARIAN PROPERTY OWNERSTATEMENT
I hereby certify that l own property adjacent to u �,s
( amof Pr
e operty Owner}
property located at� �4�.xE�'re •�.
(Address, Lot, Block, Road, etc.)
on in .
(Waterbody) , N.C.
(CltylTown and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc o
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill In description below or attach a site drawing)
Ap".4. �(4�24j allw
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner lnformation) (Adjacent Property Own Information)
ignature Lure
Gwx-
Print Type Yftma ` Prrn or Tyne NQM9 �}
Ma#insr ACGMSS 1 M.411inn AAA--
r Ulopnon%)V7v / 7 //
Date
/ tatefZlp
7ele one umber
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~ Date
(Revised 6/1t3 O12)
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