Blackwell, Elizabeth

-CAMA DREDGE & FILL
GENERAL PERMIT A B C D
Previous permit #
New Modification Complete Reissue 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
Rules attached.
Applicant Name - Project Location: County
Address Street Address/ State Road/ Lot #(s)
City - State ZIP
Phone # ( ) - _- E-Mail __ _ _ Subdivision
Authorized Agent City_ _ ZIP
Affected
El one CW EW PTA ES PTS Ph # _ River Basin
(- ) -- --
AEC S : ❑ OEA HHF _ IH UBA 1 N/A
Adj. Wtr. Body - - _ gnat /-an /unkn)
❑ PWS:
ORW: yes / no PNA yes / no Closest Maj. Wtr. Body
IType of Project/ Activity
Pier (dock) length
Fixed Platform(s)P-_(! E ,
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 Bulldozing
r
Other
Shoreline Length
SAV: not sure yes no
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed'N-ame
(Scale:
❑ See note on back regarding River Basin rules.
Permit Officer's Printed Name
Signature Please read compliance statement on back of permit" Signature
Application Fee(s) Check # 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 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/ I-888-4RCOAST 252-946-6481
Fax: [phone] 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)
(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.nccoastalmanagement.net/
Revised 08/27/ 14

I , A
Prnper-.Y, (INner Requestinlg Refm! Z.
Ma",ing A4�c-es
phomi ---------------
Ema,I! Akddrcss:
i cartil"'y that I have, sU'7,Y�ZSd
Djrpose of applying 'Orarrd obta."ing 5111 CAJ4%
necessa�y for ttie -.opose-d ellnp -nient p - - d ev p!
Clint,
ccrfthat 1 am aublonzed to grant, and ulc
Litton of Coassf management ME Vie
D mmen onds in connec-t.�,-r- -,-vi,4t ;nt
fo zt�onec
POIN opphatim,
Property Ow-m- Information.
70C
WIA I :gel
Dam -
Tits certlitcation is valid tt�mugh I ' -3-1 ;' 1 F-

i hereoy certty V�at i own vopety adiacent to
(NaTQ of Property Owner)
pWjy IOC210d at
(Addrtss, Lot, Stock, Ro4,d, etc-)
7 N C
{Waterbody) (C ity/To" and/or County)
I tne develo". ert *nmpcsed at *7te 3tCve
The applicarl ha $ scribed to *lie, s sh aawn ba'ow.
f haveno objector, 410 this proaos2t,
! !,ave C­bjiectvs to this' proposal
WAIVER SECTIQ_N
ndzrs*,zn,. that a pier. dock, rnoonrig plings, boat ramp, 1yeakwater, boa hOuse. 1. or groin
T,ust be set back a eninirnurndistance of 15, from my area of riparian access uniess waved by
(if wish to waive the s*tk1'9ck4 you must initial the aMrooMe bi2nk below
oo wsh to waive the 15setback require m�nt
! do not wish to waive the 4 5, settac* reqwremew
(Property Owner informatior"i acent propert1l", In ati*n)
4,a
........... :'�
,aRtw,a."dA4 2014j,
'tal-i for or* Cakr4w year after S'Inature,

tt OW4
twec�y ceftTfy t -a* I I :e�:�ftj' '3t!awv:
Nzirle o f Pro perry Own IC r;
(A d dress, Locn t. 13lock, Ro4d. etc,�
and!or County)
(yVatertmly)
w move
77e ap�! to on,
;Ycnosz!
C-
DESCRIPTION AND -!OR DRAWING OF PROPOSED DEVELOPMENT
thydividu&I proposing developmont must fill in doss eption joehm we 4,00 ar she Mwing";
WAIVER SECTION
toa*j ,a7,p tea,;ck�ater,
;nderstanc! *,.ha* a Cie, tOck, MO
,rust be sea back 3 7,- n cistan:c Cf 15 'v"Crr.
=ry anz'l acces% -j!;eS1-- 'W3";e:: ty
YCW must initial the ap:mmc�w'e tiank'mc-'&
Wmh to waive AMR sMtmew
-eqwaermn!
do not Na;Ve MebaCK maxemem
jProperty Owner Information)
(Adjacentpitq?erty Owrer Inform2ti0n)
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