Blackerby, Cheryl

LAMA / E MEDGt & FILL Na 70978 A B C D
�. GENERAL P RMIT Previous permit # ¢ t
❑New —:Modification Complete Reissue El Partial Reissue Date previous permit issued 1
As authorized by the State of North Carolina, Department of Environmental Quality f,
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC` QRules attached.
Applicant Name L V Project Location: County / 1,1L y 'F
Address r' l''�t' f' Street Address/ State Road/ Lot #(s)
City ��.r i .f State AJ( ZIP
—w
Phone # (�) > `�,`� f'f�E-Mail Subdivision
Authorized Agent
Affected ❑ CW ® EW ,Q PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ElIH ElUBA ElN/A
AEC(s):
❑ PWS:
ORW: yes / no PNA yes / no
Type of Project/ Activity
i,
--�.
Pier (dock) length p
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
number "
Bulkhead/ Riprap length
avg distance offshore_
max distance offshore
i
Basin, channel
cubic yards
Boat rampoatlift' -
Boathouse/ B,7
Beach Bulldozing
Other
i
i
Shoreline Length ' v^ _
SAV: not sure yes �o
Moratorium: n/a yes
Photos: yes ran
Waiver Attached: yes no
A building permit may be required by: I AA
( Note Local Planning jurisdiction)`'
Notes/ Special Conditions °f "
Agent or Applicant Printed Name
Si nature "Please read compliance statement on ack of permit
` , e?
Application Fee(s)
Check #
City ZIP
Phone # ( ) River Basin
Adj. Wtr. BodyAll A
'r man unkn
Closest Maj. Wtr. Body 1` #
Sena e
Issuing Date
o r Ire,
(Scale: j` )
❑ See note on back regarding River Basin rules.
Name
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
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888ARCOAST
Fax: [phone]
(Serves: Carteret, Craven, Onslow -
North of New River Inlet- and Pamlico
Counties)
Elizabeth City District
401 S. Griffin St.
Ste. 300
Elizabeth City, NC 27909
252-264-3901
Fax: [phone]
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
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)
Revised 7/06/ 17

LAMA / ❑ DREOM & FILL N2 f 0978 ,q g �'�j D
GENERAL PERMIT Previous permit#
❑New ❑Modification ;Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality *-�
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC 1 , 1,�_Cz
les attached.
Applicant Name (�! i'P'J( L A6X Project Location: County 22 t
Address {i4 N1 ; - Vc Street Address/ State Road/ Lot #(s) `ya
City '} • �" State .��ZIP r ll
Phone # %' Subdivision r
O E-Mail
Authorized Agent
Affected ❑ CW ff6f 0PTA ❑ ES ❑ PTS
AEC(s): ElOEA ElHHF ❑ IH ElUBA ElN/A
❑ PWS:
ORW: Yes/ no PNA yes / no
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
Application Fee(s) Check #
City
Phone # ( )_
Adj. Wtr. Body —
Closest Maj. Wtr. Body
ZIP
River Basin
PermitClWi&r's Printed Name r'
Signature
Issuing Date Expiration Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
,� IA c.k�b ,S
I hereby certify that I own property adjacent to --� (Name r- perty Owner)
property located at %02 !� D �� �S e ��
(Address, Lot, Block, Road, etc.)
on l c)h t k C'�ee in ©r/el iI j) N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
do
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
i�
u /0, d U # Ti ' ! 4-IAe/i ebat G'Af
Pro poste Lir+� Cft CN a t / uN �5
i7� 1 W"t w;1/ ,-t j� e- tw e 1AJ �l l �
�� ,�,11 b� P o s `t e>J ed a p p r0 x r %( ---fie /oc ` o u-f
�%% b o �� r,1;, I l h e a
jii Ql�e2 Cr )p -e be-td4-
b>J '� e z�c ►s+���� t e/l e IJ �(L c' u lc� a P
ter �wi if fJ�/t�e'v` 7L .ride
2 `S P W t 11 •b e c"i+-/uc. cfeoC o n► . /c �
ML
Ij leX s i N (el cam-
S
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. (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.
(Property Owner Information) Adiacent Property Owner Information)
ignature Stgnatwe
Print or Type Name Print or Type Name��
l24 b Ne as D r l zz:, -2 ►Je •���
M6ri e44 M
Mailin ddress 7 f
City/State/Zi tt ai `'l
ty p b�, ll C,-'-
Telephone Number/email address Telephone Number/email address
Date ' Date*
(Revised Aug. 2014)
`Valid for one calendar year after signature'

ADJACENT RIPARIAN PROPERTY OWNER STATE"��
I hereby that I ami property adjacent to - J �tfl . ,l 1 % f. �!'11property tocated at�01
% GU 0 de, us e (tee of Fdoperty
_r 1 C (Address, Lot, Block, N.C.
etc.)
on 1tH
(Watet)ody) (COty/Tol mubor County)
I have obte� fives to tNS Proposal,
DESCR2PT10N AND/OR DRAWING OF PROPOSED DEVELOPMENT
{lndrvidual proposing da+Vgt+OrniN t must hit in description below or attach a site drawing)
TofJa3� CC S� ttjO� d 0. I0,tod 4. 7, lO 7eMe4 13 l•�%
,dA rs , I�. S'�t _ i3 a-P
poS't+t ail a pprc xiVn- .#-e a�
tie- - s Cl- ek . Th b e. ct
2 ,5 ` . � PIC r b �,3 t �Jt
ate- rAk has C� s, .
exic""I CAP
• -z ! pier.dock, ,• •r ► •&• boat .! • bre&Wa4w, t • Stt xa or • Y
ff
must be set back a m1r*num dstance of 15! from M am of nf)anan access unless warVed 13Y
'i
do wish to waive r* 15'setback:.W3 :+
ya�
:_ • a ►