Roberts, Tom

a OCAMA / ❑ DREDGE & FILL
A B
C) D
WGENERAL PERMIT
Previous permit #
7New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commissi n i an area of environmental concern pursuant
to I SA NCAC /
�. }}
[}Rules attached.
' -,
Applicant Name t /`� j �� t9j-b
ject Location: Coun s.
Pro ty '
Address (` �- f l t:'��r�"# t'' ` % :_ ,;
Street Address/ State Road/ dot #(s)
City C, Vl ed I- , State:'' X Zip! )f) /
! � . r #�\�f..� (f�".r�-? c, n
Phone #� �)� 4> ' E-Mail
Subdivision
Authorized agent J",(A t #` +' J"./
City f t,1� r !"�'" ZIP
Affected ❑ CW p-EW ,a"A ❑" ❑ PTS
Phone # ( ) - JJRiver Basin
'r'./ (/
❑ OEA ❑ HHF ❑ lH ❑ UBA ❑ N/A
AEC(s):
�
f e" i 'T.� , nat
Adj. Wtr. Body (� -/ ! C_
'
/man /unkn )
❑ PWS:
ORW: yes PNA yes /
Closest Maj. Wtr. Body
Type of Project/ Activity
(Scale:
Pier
Fixed
'k,
Float
Finge
Groiri
Bulk
Basin
Boat
Boat
Beac
Oth
Shor
SAS
Mo
Phot
W�
MOMMEMEN-SOMENNON
MEN
MEN
length
ME
KA
number
avg distance offshore
max distance offshore
BAN
NIEMEN
MOEN
cubic yards
ram
MOMME
M.
0
EMMIM
11111111111111INE
IN
Mims
EMEEMMEM
ME
-Lline Length
MEMEEM
ot
n sure yes 'Co
torium. n/a yes no
A building permit may be required by: 4' F F+ '"`' ❑ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction) J%
Notes/ Special Conditions
�� .�ii l.: :,I°t J�_ t � ��1 r )"< , -f� � G'�L l l srYf ! r✓.J _ -
- r
Agent or Applicant Printed Name Permit Officers.Printed Name r'
Signature. "Please read compliance statement on backof permit ** Signature
Application Fee(s) Check # Issuing Date / Expi tion !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 andvoid.
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
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.nett
Revised 08/27/14

Page 1 of 1
Pcrcels - Updated 05/07/2015
D
Centerlines
NC Railroad Right of Ways
13
County Boundary
Other County
_ <all othervaluess>
Ca rt
RECEIVED
MAY 2 8 2015
http://carteret.connectgis.com/DownloadFile.ashx?i=_ags_map 1233 316084c 14064bOc7da£.. 5/21 /2015

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT `
I hereby certify that. I own property adjacent to
(Name of Property Owner)
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
17 1 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)
%6 L
RECENED
MAY 18 10b
k�-O-t'! NH 14"
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.) RECENED
do wish to waive the 15' setback requirement. MAY 2 1015
l I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Si ature
Print or Type Name
"-"17/a !19'loun
?l
Telephone Number
Date
0VV
- = 3 I
w ' ��-
w
(Adjacent Property Owner Information)
Print or Type N me
�4. � /e3
Ma&g Address
cy—/o Lc.. G e.5i� �°� ;1?/C ZtsS
City/State2ip .
Telephone Number
Date
"b (Revised 6/1 NO12)

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
hereby certify that I own property adjacent to / , jW bLLdli&r, �d &l'�,-'s
(Name of Property Owner)
property located at / s 3 1 fizz 64:2r U-, LA) ,
(Address, Lot, Block, Road, etc.)
on Y�-Q �J7/�1�/i fire- 56und , in �. /) ct C -&s , N.C.
(Waterbody) (City/Town and/or County)
Agent's Name #: Mailing Address: !ShA SID
p ' hone #. ' ents A SZ, - i.-
g fir_.___
He/She has described to me as shown below the development he/she is proposing at that location,
and I have no objections to the proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must.fill in description below or attach a site drawing)
L Yee Ieasy`
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available athttp://www.nccoastalmanagement.netlweb/cmistaff-listing orby calling 1-888-4RCOAST.
No response is considered the same as no objection if you have been notified by Certified Mail.
(P p rty wn I for ation) (Riparian Property Own nformation)
Signature ignature
/ffo.�{�s IT
/�oy3I'C % rik L�sv,es6c�
RECEIVED
Print or Type Name / Print or Type Name MAY Is lob
myiLT,41/1/w_9
/Mailing Address Ale
;� ` Mailing Address 2
///L G / V Ci �J /7 P.oar ('11 M N C- Z I �--3 CENED
City/St te2ip f7 , 01 LwD. City/State/Zip �1AY 2 a 1p15
73 t Au-3 rZeeIYC ton eri V 0--ho+jv0- ,can., �� ►.r '
Telephone umber/Email Address COS elep one Number/Email Address""
03 MAM15
Date Date
(Revised: Aug. 2014)

Tom and Lauren Roberts give Jody Ramsey and L.A. Hayes
permission to act on our behalf in the construction of a
dock addition at our home at 153 Blue Heron Lane, Gloucester NO.
Thomas Roberti:
Date
RECENED
MAY Is 1015
RECEIVED
MAy � a 10�5
p�n4-�r�r� �►t�