Thomas, Marian

OIIED
CAM GE & FILL
C) I*
HE)
ENERAL PERMIT
41
'A B
Previous permit #
El Modification EICQKnplete.Reissue E]Partial Reissue
Dateit previous perm issued
As authorized by the State of North Carolina,, Department Environment
epan 'ent of E ronment and Natural Resources
and the Coastal Resources Commission in an areaof environmental concern pursuant to I SA NCAC
rWules attached.
'T
Applicant Nam f, 'N' nel Project Location:
County
Address Street
StateRoad/ Lot
oadLot #(i) X
City i I State M CZIP
7
Phone # -Mail E Subdivision
Authorized Agent city
ZIP
0 CW _VAW PTA S Phone #
Affected 'An ;*(T
River Basin 1 K-_­(,tjK,
El OEA 0 HHF D IH D UIBA El N/A
AEC(s): Adj. Wtr. Body
L i (nat W /unkn)
El PwS:
ORW: yes"/ I- ' _t PNA yes/ "Vn Closest Mal. Wtr. Body
n
Type of Project/Activity
Z_y aZ T
(Scale:
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
umber
(Bul'k'heZ/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
CI
cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other

P
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:
❑ 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 howto complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ 1-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves: Carteret, Craven, Onslow - (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet- and Pamlico Tyrrell and Washington Counties)
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)
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.nccoastalmanagement.net/
Revised 08/27/ 14

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HCDEHR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C, Davis
Governor Director .
Date <�,4 dLl4
Applicant Dame AW eJAN
Mailing Address -'O If DA
John E. Skvarla, III
Secretary
I certify that I have authorized (agent) L4c—r< Cf ��s to act on my behalf, for the
purpose of applying for and obtaining all LAMA Permits necessary to install or construct (activity)
at (location)
,; /��r►.
This certification is valid thru (date)
Signature)
400 Commerce Ave., Morehead City, NC 28557
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
An Equal Opportunity 1 Affirmative Action Employer
DEC 16 2016
One
NorthCarolina

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I
property located at 419.
iQV17y
(Address, tot, Block, Road, etc.)
on _�U��cc. s c►/. N.C.
(Waterbody) (City/Town and/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.
have. objections to this proposal.
DESCR[PTION AND/OR DRAWING OF 0ROPOS -D DEVELORMIENT:
(Individual proposing development must filt-in description below or attach a site drawing)
lJ
WAIVER SECTION
understand that a pier, dock, mooring pilings, .Breakwater, boathouse, lift, or groin must be set
back.:a minimum distance of 15'.from myof :area .riperian access unless waived by me. (if you _ j
wish to waive .the setback, you must initial the, app.roprieite blank below.).
;; .:
do Wsh to waive the 15' setback requirement. ,
DEC 63 2016
do not wish to waive the 15' setback requirement.
(Oro -
Petty Owner Information) .'(Adjacent Property Owner Information)
=rj
'
Signature Siggatu
Print orType Name Print.or Type Name
Marling Address , M fling Address
'��-O-x 39 irr/ icS72
city% tate%Zfp CifylState/Zip
Telephone Number Telephone Numb r -
Date` /'/ Q% Date f b/ ! ©�
// (Revised 6118120f2)

ADJAGENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I Q,Vvn. roperiy adjacent to/ 's
f Name of Property. Owner)
property located at
Address, L t, Block, Road, a#c..,
( ) �7—
on P% /t�lJbZ.� S l C� r 2
�,'�� _I"l� <«� , 5�'��S : , N.C.
aterbod y
CW Y) (City/Town and/or County)
The applicant has described to me, as shown below, the. development proposed at the above.
location.
l have no objection to :this proposal.
have. objections to this proposal. .
DEC g r 1016
WAIVER SECTION '
understand that a pier, dock, mooring pilings, fsreakwater, boathouse; lift, or groin must be set
back a minimum distance of 16-fto my area of riparian access unless waived by me. (If you .
wish to waive the setback, you must initial the. appropriate blank below.),
do welsh .to waive the 15' setback requirement.
do riot wish to waive the 15' setback requirement.
ignature
Print or Type Name
av�l.l 1 h�VYIG�`
Maiiing Address
gc3 4
City%St to rp
Telephone Number
Date f b Jl Id 0 b
Information)
M9144re,
Lfvi
Print .or Type Name
Mailing Addre
CifylState/Zip
0,52-9/�
Telephone Number
Date
(Revised 611812012)