Talbot, David

12 CAMA /�❑ DREDGE & FILL No 70404 A B C D
GENERAL PERMIT Previous permit #
❑New ❑Modification ❑Complete Reissue El 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
]Rules attached.;
Applicant Name '.. I `+ Project Location: County
„ Street Address/ State Road/ Lot #(s)
Address —
City State-1 /'*" ZIP _ ,!}
Phone # ( ) E-Mail
Authorized Agent
Subdivision
Gi-4 City
ZIP
Affected ❑ CW ❑ EW 0 PTA ❑ Es ❑ PTS Phone # (_) River Basin
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body_ _ (nat /man /unkn)
❑ PWS:
ORW: yes / no PNA yes. / no Closest Maj. Wtr. Body
Agent or Applicant Printed Name {
Signature Please read compliance statement on back of permit*
f 5
Application Fee(s) Check #
PermitOfficer'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 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 - (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet- and Pamlico Tyrrell and Washington Counties)
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)
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://portal.ncdenr.org/web/cm/dcm-home
Revised 7106117

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 2t 3 / -$ ti 120n,0 /. q-, /� i— 'tk
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
3o� we /J.L•fl�s �w, ��— 1��1 S
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: ooGxf , CJ �lL
at my property located at
in
1 furthermore certify that I 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:
Signature
L L
Print or Type Name
Title
1 30 1
Date
This certification is valid throughl_ l

AUJAGEW mpAmAw Wff '
I tle"8by cerfifYftt I OvM PrOPerty adjacent to —ilgv � cf
PrOP9rtY located at (Name of Prop" Owrier)
on (Addren, Lot isloc"13ad. ep-,)
n
N-C.
'
jUjtyffown and/or County)
T Ms 3PPIICant has deSWbed to Me. as shown be, 10 augn. ova, the development Pmpoeed at the abon
have vo oblection -io ffft propcsai.
!have objecttan-s .0 this proposal.
a PUPTION PODIOR DRAIJ,,'A'd t3 p
ROR
66EO—PA�IEWT
kg dewdption hdow OF aftech a sft dMWIng)
�rb LI
PW. dock MOOft pilings, bOQt Bpi breakwater, boathouse, rdt or gmin
MUK be sK bec* a ff"MUM T" ,ftnce of I 'M my area of r. 'D
"Faive the setback, you M'Uq�t inftw aran acceft UrdeM Waived by
I do %aiish to Waive the ftVPM-Priate blank befow,)
16 s6thacK Tequirement.,
I dc, not wish to jrraive the 16 setba_ ,k reauirament
ftom.dry own Wformawn)
(Ad*e�nt�
Propecty
Pfint or
6? 4'v"J Prtnt or Tyw AWre
'5'—
WNW Address I�L- -? �7-
c4dStalizziF
1P
-
elePhOne Jv'JMbc-,.1 erna,�I 5 -x-
—addm, ------------
Telephone AfUMb9rIemail a—d----
address
2� I X2
-Date*
'Valid for ane C--dgndwYear afteraikgriature O'RevfsadAug- 2014)

ti
ADJACENT_ RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to U 4')'s
property located at L 3 am Qf Property Owner) `
(Address, Lot, lock, Road, etc.)
on %3i+�flc �it�'z-�L in o�G�. �. ✓A--,-- , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
1 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)
120 - Z07
S•w,,1;.
WAIVER SECTION If
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) (Adjacent Property Owner Information) K'
Signature Signature*
Print or Type Name Print or Type Nag+I�q
Maili Address Mailing Address
City/StaterZip City/State/Zip
Telephone Number / email address Telephone Number / email address
Date
*Valid for one calendar year after signature`
Date*
(Revised Aug. 2014)