Crow, Dana

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Dr —AMA / —1 DREDGE & FILL A B C D
GENERAL PERMIT Previous permit #
CNew 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
City State `
Phone # ( ) ~' r - E-Mail
Authorized Agent
r"
ElCW ❑ EW b PTA El ES ElPTS
Affected AEC(s): ElOEA ❑ HHF ❑ IH ❑ UBA ElN/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 y
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
t
t
Agent or Applicant Printed NNaam!/e> �
44
Signature Please read compliance statement on back of permit
Application Fee(s) Check #
Street Address/ State Road/ Lot #(s)
Subdivision
City — ZIP
Phone # ( ) River Basin _
Adj. Wtr. Body "j + nat man /unkn)
Closest Maj. Wtr. Body
(Scale:
❑ See note on back regarding River Basin rules.
Permit Officer's Printed Name
Signature / /t 7 r
Issuing Date ExpirB ion 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 L 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/ 1-888-4RCOAST
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)
http://www.nccoastalmanagement.net/
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)
Revised 08/27/ 14

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: T) Q �,
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
tve-
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no
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Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: l z,T,-
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at my property located at Ili
in CRA ✓6 �/ County.
U.A . lVe-w &&V ,, y/C
/ furthermore certify that l 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:
j� Signature
A (
in/ aA l &0 �.i
Print or Type Name
(� LA) Af 2
Title
Date
This certification is valid through A) / / � 9-1

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: R ar✓A `/;dcp�
Address of Property:
(Lot or Street #, Street or Road,
Agent's Name #: BDt1
Agent's phone #(Z s �,� �✓L?
('4VCA)
Mailing Address: 3 iq 13eA -tx& (. Aee-k
f'hcAV,-, � ) YY ✓ 10
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. A description or drawing with dimensions, must be Provided with this letter.
�_ 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
availableathttp://www.nccoastalmanapement net/web/cm/staff listing or by calling 1-888-4RCOAST.
No response is considered the same as no objection if you have been notifiled by Certified Mail
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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.
(PTPefty Owner Information)
Signature
7]i�
,lJv�+b aA
Print or Type Name /
Mailing Address
/[(&U) 6,e�N
City/State/Zip
Zi .3 // q "
erne NumberI Email Address
3-,�-Is
Dale
( ari erty Owner Information)
Si mature
trOe;r
Ct
Print or Type Name j
Marling Address /
CitylStaatye2i
�l �NCth J c C-o
lephone Number Email Addre s
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Dale
(Revised Aug. 2014)

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: 4e✓A C-p dC,,�
Address of Property
t1d Fie- P-Al AIC C4 vG�
(Lot or Street #, Street or Road, City & County)
Agent's Name #: 8Cti ��y �yi
\ Mailing Address: %Re,a.4-�- ('A'ec-4
Agent's phone #��) S l� �� �/-A t f'V-i o
a
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. A description or drawing with dimensions must be provided with this letter.
A'(1—
I have no objections to this proposal. I have objections to this ro osal.
p p
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 http://www.nccoastalmanapement net/web/cm/staff listing 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, boat ramp, 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.
(Pr9p-efty Owner Information)
Signature
D,I,NAeLk)
Print or Type Name
-1 I ! -Fk e,vt
Mailing Address
City/State/Zip
Ogt-��
elephone Number/ Email Address
Date
(Riparian Proye� Owner Information)
il l,L4Ai-4 1tC
Print or Type Name
Mailin Addre s
Ci/ttyy/State/Zip
elephone Number/ Email Address
.... 4� l
Datif
(Revised Aug. 2014)

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