Johnson, L. A.

IA/
❑CAMA / ❑ DREDGE & FILL A B C 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 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
❑ CW ❑ EW ❑ PTA ❑ ES PTS Phone # ( ) River Basin
Affected
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body (nat /man /unkn)
❑ PWS: i
Closest Maj. Wtr. Body
t'IRW vac / nn PNO vps / nn
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 ` s `
cubic yards ' t
Boat ramp .,
Boathouse/ Boatlift —�
Beach Bulldozing
Other
Shoreline Length
SAV: not sure yes nQ
Moratorium: n/a yes no
Photos: yes 140 i
Waiver Attached: yes o�
A building permit may be required by:
( Note Local Planning Jurisdiction)
Notes/ Special Conditions ^! }
_
Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit
Application Fee(s) Check #
(Scale: r I ) I
❑ See note on back regarding River Basin rules.
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 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 E 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
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ I-888-4RCOAST
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)
http://www.nccoastalmanagement.net/
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 08/27/ 14

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: L /4 ? TO H rv'f d Ki
Mailing Address:
Phone Number: q (n A g '7 ol-L O
Email Address:
I certify that I have authorized 14LI-D h/1 r/ Ak ,o 1)•��-r� ,
—r Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
l�
—i -e-,-e ► A-t'
at my property located at
in (' ,��6j?-►'�j'�County.
Ci ff G-
n
1 furthermore certify that 1 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:
V�
ignature
L A
Print or Type Name
Title
Date
This certification is valid through I l
RECEIVED
APR 18 2018
DCM- MHD CITY

n
ADJACENT RIPARIAN PROPERTY -OWN t_R STATEMENT
'I hereby certify that I own property adjacent to ,L {�E24Z 1U✓ is
(Name of Properly Owner)
property located at J V -" L7-67 e--&
(Address, Lot, Block, Road, etc.)
onin N.C.
(Waterbody) -(Coy/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
I o ti n.
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 aL�-)
f
35
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WAIVER SECTION
understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15' from my area of riparian access unless waived Pa6`®
wish to waive the setback, you must initial the appropriate blank below.)
do wish to waive the 15' setback requirement.
tV 18 2018
I do not wish to waive the 15' setback requirement. DC ry HD CITY
(Property Owner Information) (Ad' cent Prop rty n Information)
i atu _ Sign ure
L�_ ,1 D H r/1��
Print or Type Name Print or Type Nne
Mailing Address Mail* Address
City/State/Zip City/State/Zip
i l o 3B5 �zy�
Telephone Number Tele on Nu ber
Date Date
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY-OWNUR STATEMENT
I hereby certify that I own property adjacent to 1 . 4, i o /-/ A-401 J is
n T (game of Property Owner)
property located at 1— �a,K
(Address, Lot, Block, Road, etc.)
on in C- N.C.
(Waterbody) (Cit Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
1 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)
k
.a v
l JLs i
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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.) RECEIVED
do wish to waive the 15' setback requirement. APR
18 2018
_ —I do not wish to waive the 15' setback requirement.
®CM- IVIHn �
(Property Owner Information)
Si n tur
L
Print or Type Name
ail�ress
C►tyiS
le 3V ,� '
Telephone Number
Date
(Adjacent Property Owner)nformation
Print or Type Name
a 4 :7 )e,- C/ ecru_ Iv
Mailin Address
G
City/Sta eelZip
U-Z�o - 9671,
Telephone N7�M2
b
n a/8
Date
(Revised 611812012)