Shelton, Connie

c17�
,. P6,
R.ms +' 4
a gP E?
x
_.
- -
i 1 ii. �lil

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 consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar - Pamlico River Basin Buffer Rules IN Other:
FM 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/ 1-888ARCOAST
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

TL4 5..
Applidarit-
�
Date:
l V
Describe below the HABITAT disturbances for the application. All values should matc VenamMe, and units o m e ent
found in your Habitat code sheet.
Habitat Name
A
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance -total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp.
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
Dredge 0 Fill Ej Both [I Other)!,
Dredge [:1 Fill El Both [I Other El
Dredge 0 Fill El Both El Other El
Dredge El Fill El Both El Other 171
Dredge El Fill M Both El Other El
Dredge 0 Fill El Both'[] Other [I
Dredge El Fill [I Both El Other [I
Dredge El Fill f-1 Bothn Other 0
Dredge 0 Fill D Both 0 Other El
Dredge El Fill [I Both [I Other [I
Dredge El Fill [I Both 171 Other El
Dredge El Fill El Both El Other El
Dredge El Fill [I Both El Other 171
Dredge [I Fill [I Both El Other [I
Dredge El - Fill El Both [I Other [I
rfevised. 02/03/10

a

9
P\"t �ga M
Iftrrlyv
3
� 09
�"i a�5v e 5cuv�
1�
V
C
o
�

Adjacent Riparian Property Owner Statement
(FOR A PIER/MOORING PILINGS/BOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to f ,0%�� �zi�O s
� � D� Name fProperty
�v
property located at
Lot, bloc , road, etc.
on v 6 `^ C t� in �1�2 "1-=��2 C es? NC
aterbody Town and/or county
He has described to me, as shown below, the development he is proposing at that location and I have
no objecti s to his proposal.
I do not wish to waive the setback requirement.
I do wish to waive the setback requirement.
Description and/or Drawing of Proposed Development
(To be filled in by the individual proposing development)
1
Print or type name
2) 1'-10 q101, �
Telephon :�7
t� C-13
Date
3s'

1.2/12/2013 17:13
03/23/2006 00:40
9103476343
2527264092
PAGE 01/01
IMACOASTALMARINECO PAGE 021919
1.hditby cer0;� tvt I own property 90t1cant
ttto,
prdorty loos eei ,at .Aa Wass
on In
i;�fialribbdy►'�
and/or
N.C.
The rappllcaro✓�,e s c escrllx4i to me, a:. shown Flow, :;h! a developmtaht proposed at the above
lac�vn.
I h a�rt no ot,,p��ctiort to this proposal,
I have± object1ms to this 1)'oposriil.
— —__ --w��I`I�rt Aw1�4FMw�,�WN wnw�wA•Y�MI,��w
Ii ii'M1PTloN !AND16R M1AlA NG OIL PH' )POSED DEVELOPMENT
(1na1►idrralAli rr PqgdevG±/eptrrantatuit>'FIRn dczilpffa1` nworattachiaate.drza n_q)
x
0
c o ;1 J)r
clings, braakwat±tr,thouse, lift, or groin must be set
back a minims m Ifstance oil 15 ftam rn, area of ripariao across unle;!m waived by me. (if your
wish -to waive, to -seat moo ytiu mast in* Rl the appropria!s blank below-)
1 io vis.i to wah e the 151 se aback requirement,
I to io1 wish to waive the 1 Y setback r±equir anent.
(prop" Or rer ltaflmataep) (Adja-;,a±nt Property owner lnforimaton)
N14W=
PnW o 'type Namq Yl 00 V-
UV
il"
lW
(� rsrlinc ss -�
Cliy/St� w. •. , } �.� City/St ifelzrp Ct t
T�lep no Date
Num1 ��r Teleph ,ine Number
.Dar '
(Revised &18/2012)

North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Michael F. Easley, Governor Charles S. Jones, Dirlector William G. Ross Jr., Secretary
Date
Applicant Name
Mailing Address
I certifythat I have authorized (agent) #' a �-- to act on m
(g ) Y
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) 1C
at (location)
09 0(fs
This certification is valid thru (date) J Signature ivy 1t "
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] FAX: [phone] Internet: www.nccoastaimanagement.net
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled 110% Post Consumer Paper