Shivers, Norma

NCAMJ EDGE & PILL 72
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�,iOv 668 A B C D
'NewENERAL PERMIT Previous permit #
ElModification OComplete Reissue El Partial Reissue Date previous permit issued
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
As authorized by the State of North Carolina, Department of Environment and Natural Resources
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Applicant Na al
4 v Project Location: County
/ ) Address— Street AddressState Road Lot #(s CityA"
State k;CZ' I P k
-Mail
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bdivision ubdiVision
Authorized Agent Ci k ZIP
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Affected-Cw qEW QPTA '&ESEPTS Phone # ver Basin I
El OEA 0 HHF ON 0 UBA D N/A
AEC(s): Adj. Wtr. Body? (nat ifinnan /unkn)
L1 PWS:
Closest Maj. Wtr. Body
ORW:: yes no PNA yes ,(;no
e of Pr *ect/ Activity
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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, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
0 Tar - Pamlico River Basin Buffer Rules
El Neuse River Basin Buffer Rules
EJ 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 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/ I-888-4RCOAST
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

CAMAL REDGE & FILL
6 6, 0 A B D
ENERAL PERMIT Previous permit #
ew OModification DComplete Reissue ElPartial Reissue Date previous permit issued
5-authorized by the State of North Carolina, Department of Environment and Natural Resources
id the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
•El gulps attachO
)'fi Ant N p i;: ar�e Project Location: County
rossS i Street Address/ State Roadl Lot #(s)
ty
State 1t I P
lone # A I -Mail Subdi Isil n U '
V V
Ahorized Agent "t
City
ZIP
0 CW 'N�EW 1(R\PTA S-, El PTS X 'lover Basin
Phone
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�Yes It no PNA yes , /(no kw, Closest Maj. Win Body
YPe of Project/ Activity
(Scale:
Pier (dock) length
Fixed Platform(s)
, Floating Platform(s)"
,Forger pier(s)
Um er
.4 11
�DO.ea Riprap lengte,77
avg distance offshore
max distance offshore
Basin, channel
cubic yards
pat ramp ----
3pathouse/ Boatlift
3'Oach Bulldozing
ether
3horeline Length
SAM not sure yes n,
Moratorlum: n/a yes
'hotos:. yes �no
ftiver Attached:
yes /no
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building permit may be required by:
Note Local Planning Jurisdiction) -J
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See note/on back regarding River Basin rules.
or Applk
Alf -
re. e react compliance statement on backof permit"
1onrFee(s) Check#
1,16)
Issuing Date
J
Expiration, Date

:1jf,ER: COMPLETE THIS SECTION COtTIPLETE • I • I I I
■ Complete items 1, 2, acid 3. A. Signature
■ Print your name and address on the reverse X � ❑ Agent
so that we can return the card to you. ❑ Addressee
■ Attach this card to the back of the mailpiece, B. eceived by Pri Name) Date of Delivery
or on the front if space permits. VI.G..� N�i/S I/
Article Addressed to:
sT
e �
D. Is delivery address different from item 1? ❑ Ye:
If YES, enter delivery address below: . ❑ No
II I'lllll IIII I'I II I II I IIII II II II I II I II IIII III 3. Service Type ❑ Priority Mail Express®
❑ Adult Signature ❑Registered MaiITM
❑ uR Signature Restricted Delivery ❑ Registered Mail Restricted
ified Mail® Delivery
9590 9401 0159 5234 1500 13 ❑ Certified Mail Restricted Delivery ❑ Return Receipt for
❑ Collect on Delivery Merchandise
2. Article Number (Transfer from sPrvirP iPhail Delivery Restricted Delivery ❑ Signature ConfirmationTM
7 015 0640 0007 5289 6 510 iil ❑ Signature Confirmation
it Restricted Delivery Restricted Delivery
r
PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receipt

wps TRACm #
will
First -Class Mail
Postage & Fees Paid
USPS
Permit, No. G40
9590 9401 0159 5234 1500 13
United States
Postal Service
• Sender: Please print your name, address, and ZIP+4® in this box*
o rnY O�arfw-
�� �v�fi N • C a16 S�

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 6�("0\ cy_' %QEls
Mailing Address: I� ?) S 4 �\(J\1
Phone Number:
Email Address:
I certify that I have authorized
— a\(� - - os� �
/ Vy IIl/ \!VI Ill GIVtVI
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: CVS J� d�
at my property located at 135 C T�A ()asY K ,
in r�­cCek County.
I furthermore certify that 1 am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature
Print or Type Name
Title
/ 6 % c�
Date
This certification is valid through 67 / 6 I / Ae
0CM., WIVJD
MAY 0 4 2016
CITE

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1
` I hereby certify that I own property adjacent to LUM rA 01 rS 's
1 (a of Property Owner)
property located at 13 5 C �5 0
(Address, Lot, block, Road, etc.)
on , in c N.C.
(Water ody) (CItyffbwn and/or County) A
The applicant has described to me, as shown below, the development proposed at the above
n.
have no objection to.this proposal. a
have objections to this proposal.
;z
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT.
(Individual proposing development must fill in description below or attach a site drawing)
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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
wis to waive the.setback, you must initial the. appropriate blank below.)
do wish to waive. the 15' setback requirement. 1
do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
Signature
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number
Date
o
Si tore ,
Print orT eNaE tom i
a11ingAddr MAY 0 4 2016
CI Ist telzip
Telephone Number
Date
(Revised 611812012) _