Tysinger, Jr., Thomas

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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, certifythatthis project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
M Tar - Pamlico River Basin Buffer Rules 10 Other:
a A., 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 Headauarters
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

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: Tysinger
Date: 8/28/13
General Permit #: 63026C
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Name
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
OW
Dredge ❑ Fill ❑ Both ❑ Other ®
168
168
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
252-808-2808 :: 1-888-4RCOAST :: www.nccoastaimanaaement.net revised: 02/03/10

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
—1—homQS f USrrlcre��
Mailing Address:
I certify that I have authorized (agent) Sbt\s Marge Comp . to act on my
wt Me,.w\ -j-. -ID, F\ n-% S
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) R66\V: on
at (my property located at) SPa (-XA k c T) 6 V 2 KNe u-D ork- K)C
This certification is valid thru (date) 1 L 'S i f 2U('-�L,
Property Owner Signature
0
Date

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM
Name of Property Owner:
Address of Property 1 2(ra 5' 4A I� (. 11k- a �FJ Gv 20�P ` �2,80
(Lot or Street #, Street or Road, City— & Co nty) �i
Applicant phone #: 'Z Z " Mailing Address: 401� i.c'�v R.C':�
----- --I-
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing: the development
they are proposing. kderth tl is letter.
�`4 YQ I have no objections to this proposal. I have objections to this proposal.
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 at www.nccoastalmangementneticontact dcm.htm or by calling 1-888-4RCOAST. No
response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift 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.
r1ptoperty Owner In ation)
/0
Si tune omaS 4,
Print or Type Name
1507 14111 by' i 6w P-07�
Mailing Address
414z'v1 V 1 L , ���, 27?"5F
City/State2ip
Telephone Number
4-*13
Date
(Riparian Property Ownerjpformation)
0, J��� �
"Je -y�-e- Py' N , w `
Print or Type Nathe
c�
I / q 6 'S ,, A C,, P, �, �
ailing Address
IV 0 w P a
CitylStatelZijd
Telephone Number
Date �

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
i
Name of Property Owner:
Address of Property: a 6 Sea ()CJ-2 T�-', v-e Mew1 ell— - L�rfe,-
(Lot or Street #, Street or Road, City & County)
Applicant phone #: Mailing Address: I r a(o sen- 65e-T)r,
1\�ewpbra KI C a KS-70
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
. . . . . . . . . . . . . . . . . . . . . . . . . . . .. ... ... ... ... ... ... ... ... ... ... ... ... ... . . . . . . . . . . . dimensions,
. . . . . . . . . . . . . . .
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
t_- I have no objections to this proposal. I have objections to this proposal.
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 at www.nccoastaimangement.neticontact-dcm.htm or by calling 1-888-4RCOAST. No
response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift 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)
Signature
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number
Date
(Riparian Property Owner Information)
)gnature
JotY,' GP_, A, Lc)Tr
Print or Type Name
Ming Address
JP"/Q n t/lie IJ I q'a�'
j�
City/State2ip
Telephone Number
c�h 2.013
Date
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