Youngblood, Harold E.

X
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'PCAmA / El DREDGE& FILL
GENERAL PERMIT A)C— Previous permit #
New ElModification ElComplete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pUrsuant to 15A NCAC
El Rules attached.
Applicant Name Project Location: County
Addresi. Street Address/ State Road/ Lot #(s)
City State i.ZIP
Phone # E -Mail Subdivisiorf
Authorized Agent city ZIP
PTS ES
Phone # River Basin
0 Cw El EW 0 PTA [I El 7
Affected
El OEA 0 HHF El IH El U13A 0 N/A
AEC(s): Adj. Wtr. Body a (Lnai /man /unUn
El PWS:
Closest Maj. Wtr. Body
. yca I — 7..
Type of Project/ Activity
(Scale:
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
cubic yards' --
Boat ramp
Boathouse/ Boatlift
Beach Bull-dozin
Other
Shoreline Length
SAV. not sure yes lno
idd
Moratorium: n/a yes
Photos: yes
--I---�
no
Waiver Attached: ;,;es no
A building permit may be required by: See note on back regarding River Basin rules.
Note Local Planning jurisdiction)
Notes/ Special Conditions, 7 i L
J
5
Agent or Applicant Printed Name
Signature Please read compliance statement on back,ofpermi,t,**
Application Fee(s) Check#
Permit Officer's Printed Name
Signature
Issuing Date Expiration Date'

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 I) 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 consistentwith the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
❑ Tar - Pamlico River Basin Buffer Rules
❑ Neuse River Basin Buffer Rules
❑ 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 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/ 1-888-411COAST
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 08/27114

... ......... ... . -
AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit:
Mailing address:
Telephone Number:
I certify that I have authorized lev FrDDK-5 (agent/cor fl
ntractorl
to act on my behalf, for the purpose of applying and obtaining all LAMA permits
necessary for ttie proposed development of
be �ee
1c
at my property located at S+ it
This certification is valid through 12-31 —15 (date) — I.
(Property Owner Information)
Signature
4��d/, E yweu
Piffit or Type Name
Title. cc. owner or trustee for Propelty
Date RECEIVED
OCT 2 3 2015
Telephone Number
Lt�I f& - vl) 6-e-Mrt-
, ,, Wal, i, V, 6 tw�, DCM- MHD CITY
Email tddrees

MIA
0
ADJACENT RIPARIAN PROPER -Y OWNER STATEMENT
--1 f
I hereby certify that I own property adjacent to ---
's
4 r (Nam of Property wner)
property located at 1 '�r'l �j - 'e
__ �
(Address, Lo lock, Ro , et¢.)
on p�eci�Ga v � ��tf1 , in ct /% . — _, N.C.
pp
(Waterbody) (CityfTown andlor County)
The applicant has described to me, as shown belo'rr. the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposa'.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must Tiff In description below or attach a site drawing)
WAIVER SECTION
understand that a pier, dock, mooring pilings, boat ramp, brea<water, boathouse, lift, or groin
;rust be set back a minimurn distance of 15' from my area of riparlan access unless waived by
tme. (if you wish to waive the setback, you must initial the aggro; riafe blank below.;
_
I do wish to waive the 15' setback requirement
I do not wish to waive the 15' setback requirement.
(Property Owner lnformatiorn (Adjacent Propeerty Owner information)
F�Qt:Gt2tY�'(( V T S t t7rt�i'
%tiYt'icS /LLL`ClIwrL..1 'QN_
Prin, or Type Hams �s Frim orT .arne i
Mai;ir, A dress ` ,b�,a-tirg Ad^ress j}/
6 1
TelephoneNumherfar,1aiIaddress Tefe-pro e^rum erlemaila dre� _s
parte I Date"
'Valid for one calendar Year after signature'
OCT 2 32015
DCM - MHD CITY

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FRECEIVED
OCT 2 :12015
®CNA- MHC CITY

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit:
Flailing address: G qc-5. A4,11
Telephone Number:
I certify that I have authorized t ri �? ('agent/contractor).
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for t`�e proposed development of
at my property located at
This certification is valid through 12 -31 —15 (date).
(Property Owner Information)
Signatu
Pru?! or Type Name
Tine, co. owner or tnistee�for pr�op�e, ity
Rafe
IL ?l� /P5 /
Telephone Number
Email . ddre s

W
RN
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adaceni to
1 'C Y 0 W 0 04 's
t (Nam of Propertytwner)
procerty Located at _ or'"t S•'t. -�
�i a
r �+ j
(Address L o lock, Ra , et .)
on ,i1c?A�tcl . in �/ctr`, N.C.
(Waterbody) (CityfTown andlor County)
i he applicant has described to me. as shown below. the development proposed at the above
location.
1 have no objection to tn;s proposal.
i have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must Orli in description below or attach a site drawing)
3
f
RECEIVE®
OCT 2 3 2015
®CM- MHD CITY
WAIVER SECTION
i understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set bac}: a minimurr distance of 15' from my area of riparian access unless waived by
ire. (if((you wish to waive the setback, you must initial the appropriate blank belay.;
C� 1 do wish to waive the 15' setback requirement.
{
I do not wish to waive the 15' setback requirement.
(Property Owner Information,) t (Adjacent Property Owner Information)
—r-�
Si��tcrttrrc�° S. nartire'
Print or Type tveme Prsr, or Tyr Name
4i8ilin A d; ess j % A'`tfr�s'7..16t��_ ?yt��'t"�V
cirylS atelz (�=�- GitylS :a2iP
Te;ephane Nu,rnber:'&mail address Telept, r&,Numberlema Eiddrelss
Date Dxe*
(Revised Aug. 2014)
'Valid for one calendar near after signa-ture

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