Vandersea, Brian (2)

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ikJ,CAMA /.y DREDGE & FILL`
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GENERAL . PERMIT Previous permit#
j f New ❑Modification ,, El Complete Reissue El Partial Reissue ,: Date previous permit issued
As authorized by the State of North Carolina, Department "of Environment and Natural Resources
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and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
Y, �Sl Rules attached..,j ,
Applicant Name ` ;' �+ !, l� a Project Location: County r
t Street Address State Road Lot #(s ,nI-ilft 1
Z1 ,l l
Address t:
City t .fe i i1 �6 State I� ,--ZIP !1-
Phone # (�)t :�"lix ' , Mail Subdivision ...
Authorized Agent 4 t .f � . { (� _ City 1 ? j f ZIP
Affected ❑ CW -`SEW ' ,�PTA ES ,,gPTS Phone # ( )... River B in
❑ OEA ❑ HHF ❑ N ❑ UBA ❑ N/A ;^
AEC(s): Adj. Wtr. Body #, ``.! •.� nat , r n unkn
❑ PWS: t If1
Closest Maj. Wtr. Body
ORW: yes (no PNA yes no./ )
✓ \.
Type of Project/ Activity i J
Pier V—
I
Floes
Fingi
Groi
Bulk
Basil
Boat
Boat
Beac
Othi
Shor
SAv
Mo
Phot
Waiv
A building permit may beetluired by:
(Note Local Planning Jurisdiction)
Notes/Special Conditions r k)j
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Scale: t
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CAgent;br plicant Printed Name -
PermitOfficer's Printed Names- •-- '..,'
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SignayyurPleaser&ad compliancestatement onbackofpermit*
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Signature'
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Appl{cationFee(s) Check
Issumgf
Expirati(o+n.D(atet

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 how to comply with 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.net/
Revised 08/27/14

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: �B� is �4&D XKe refs Iq 2d-PrS.e,,q
Mailing Address: O S hIF m'P-nlea5
Phone Number: 4�3 S o zS
Email Address:
certify that I have authorized rb L.O f)/-enGin's C .
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: 'ecErl? inc--, ym . '5(E-"0a g-Gl
at my property located at-1 C01571 L. oh fo i l se
in CA County.
l furthermore certify that I 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
3riau V a Nc-e r'sev4-
Print or Type Name
Tide
fo , n 16 DECEIVED
Date O C T 2 0 2016
DCM- MHD CITY
This certification is valid through I I

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to I A-W' L--n a! k-4 �e ny U,A r-d -e'relig-
Tame Owner)property located at 10S C In I rVIGA'e � P
1'® of of p
(Address, LoA Block, Road, et .)
on CA M ►� L , in INC ILt-Jolt SkIaL�E5, 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.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fi/l.in description below or attach a site drawing)
C,I Ia c¢ 1) 1�► ��� �N �r�.� o J�7 O LO VV49-4
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distance of 15' from my area of riparian access unless waived by
me. (It you wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement. RECEIVED
1 do not wish to waive the 15' setback requirement. O C T 2 0
2016
(Property Owner Information) (Adjacent Property Owner Information)
1UDCM- MJHD CITY
mature r �Q N 04 t'r� Stgn� /V
Print or y e Name Print or Type Name
©S h ► rrl,.c I'n
Mailing Address Mai, g Addre s p
1-1► k1 . N .c. 2-,511-�- s-� 1lm p, � 011 n n R es
C vatelZq C).Z.� City/S te/Zip l
Telephone Number/email address Telephone um er/email ddress
l ►:1 ) � 1�5A � J4-7 a 9
Date Date*,
(Revised Aug. 2014)
*Valid for one calendar year after signature*

m
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to be") A N G „, 0 rACc W V 41-de"s-c 4 's
(Name of Pro7ML-61,01L,
wner
property located at O C �Z �N eye Tier-'-
(Address, Lat. Block, Road, etc.)
N.C.
(UVaterbody) (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.
i have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development thirst ffin description below orattach a site drawing)
V)o c-)L
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distance of 15' from my area of riparian access unless waived by
me. (it you wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement
do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adja nt Property wn Inform n)
U
� � e 1C/A_.r - ... _ � (� ti!)-e l ✓d- Si a(�{* C 61 C i� G- •PJ
Print or TVDe Name Pri e or T N Oki
dl- i /
Mailing Andress 7-2 S 17 - aili c Ts /Ud A'�s /
QW3ty'�t p ?—� City/S ate�i g
I `f z3 sus
Telephone Number/email address Telephon Num r/%it address
1 � -/ �'
Date Date * C : � vised Aug. 2014)
''Valid for one calendar year after signature: E
OCT 2 0 2016
DCM- MHD CITY