Beasley, Philip D.

CAMA / -. —]DREDGE & FILL
-. GENERAL PERMIT Previous permit # A B C D
New Modification ❑Complete Reissue EPartial Reissue f 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
❑J Rules attached.
Applicant Name Project Location: County -�
Address
City_
State ZIP
Phone # ( );
E-Mail
Authorized Agent
Affected ❑ CW
EW PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA
❑ HHF C IH ❑ UBA ❑ N/A
PWS:
ORW: yes / no
PNA yes / no
Type of Project/ Activity
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 Bulldozing_
Other_
Shoreline Length
SAV: not sure yes no
Moratorium: n/a yes no:
Photos: yes '
Waiver Attached: yes no
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
F 1-`tom:. I In 'il r, `, i i i
Agent or Applicant Printed Name
Signature'Pleaseread compliance statement on back of permit
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP
rr
Phone # ( ' _ )' • diver Basin
Adj. Wtr. Body f i�tn an unkn
Closest Maj. Wtr. Body
e
(Scale: )
❑ See note on back regarding River Basin rules.
t�
Permit Officer's Printed Name
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 how to comply with 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/ 1-888ARCOAST 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.nccoastaimanagement.net/
Revised 08/27/ 14

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit: Philip Beasley
Mailing address:J/ � +t��R.S �� �� �'�, i�C 7� �� 2YPn U ./�:"Zj N c
Telephone Number: 1ZL6—. �3 6 �
I certify that I have authorized Doug Banks
(agenticontractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of adding new dock and boat lift.
at my property located at 254 Old Causeway Road Beaufort NC
This certification is valid through t (date).
(Property Owner information)
IV.; 112, " 0 r, --' 4e-
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Signature
Prin�^ ( -JF
Tyyppe
PGtsl% ��
Title, co. owner or trustee for property
-3-yS- -Z,-l9
Date
Telephone Number

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