Rush, Frank

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 Environmental Quality -� 110
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC ®Rules attached.
C^ L4) Project Location: County
Applicant Name_. �^
Address u _ Street Address/ State Road/ Lot #(S
-- State ,f C. ZIP e 'irh
City - --
±��
Phone # (__ ) k..
E-Mail
Authorized Agent
f
�❑
Affected r OEA
1-1 HHF ❑ IH UBA ❑ N/A
AEC(s):
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 jj yy/ �
Boathouse/ Boatlii i ('�__
Beach Bulldozing
Other
Shoreline Length
SAV: not sure yes
Moratorium: n/a yes ; no,/
Photos: yes no i
Waiver Attached: yes no
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent
orApplicant Printed Name
Signature ** Please read compliance statement on back of permit
Application Fee(s) Check #
Subdivision
-�
City /,,fit *- t ZIP J
Phone # (__) River Basin
Adj. Wtr. Body (nat man 7unkn)
Closest Maj. Wtr. Body
si
(Scale: )
7.p�-
e note on back regarding River Basin rules.
. 1 " ) " -
Permit Officer's Printe Nam ,
Signal re
Issuing Date EApiratiob 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

ADJACERIPARfAN PROPERTYOWNER STATEMENT
NT
y '
,.,
hereby certify that I'own. property adjacent to
. .' •. - ' -(Name of. Property Owner) .
'
. .
erty located at 4.1 t act Ztr it
prop _
.
Address Lot Bloch Road, #c.•):
on
i
(Waterbody-j... _._ •.. (CityRown andtor-C��niY)
__.. _
The applicant has .described to me, as shown below,'the.devlopment proposed .at the above.
location..
T have no-objectioo to .this .proposal: : •
; <. -
r.: .
have. objections to this proposL .- .
y`
DESCRIPTIONRiO DFfQ►fRClhla OF pROpOSED.DEVELOPMENT:
lndiiidual ro os�n deveto mint rr�ustirl °fin lescrl icon below or attach a site drawrngj
LA
- T.-L
-
' :Y '`•
.i
V ''AFVER S QTIAN.:
_ L understand 1--that pier. dock, rrootingilm s,.breakwaer, boathouse; Iiit, or groin must beset
t5 Xipanan•.access unless waived by me. (If you
;
back a Minimum dist nos of ftom rrty area of
wish'to Walve.the.eet ack, you must iriltia[the apprv�riate blanl� below.).- . .
' (db wish. tq vuaive.tie 15"se{ak requirement. -
. :..
f ;
�. I do not wish to waive the 16' setback'requirernot
t
Ad acdtit.Pi�perty Owner in ma ion.
(Property binrner informatiohj. :: = , l
Cigna `-are " ' ". toreApe
A/
Print or jp• a Name P f r T e Name
� J
INai7i ddr. esa , M Tess'
�kc
Telephone Number _ :—elepli a Number
AF
Date Date
(Revised 611812012)
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ADJACENT RIPARIAN PROPERTY OWNtR STATEMENT :• .4
I hereby certify that I own. property adjacentto . a,A
(lyame 9t. PXoperty Owner) ,
property located at
' Address, Lot, BIock, Ro.d,
on
.(Waterbody� yfFow .
_ .-
` n andlor Coi�•n
(C�t
The applicant has described to me,. as shaven WOW, `the. development proposed at the :above.
b ).�
T have no"oejection to .this .proposal: ':: =4
have.objecfion to this proposal.
DESCRtP110� AntD/OR QRA1lICIN.a OF P.ROPOS9d DEVELOPMENT"
ndlvidua/ to osln-dewelo ncttf triust illaahew oin'desdrsiwingj
Al
:=
:.
`Z11VhR SEOTIAN
nderstandthat a' pier 'dock rrroorip ` .' 'i1 .`.s;' reakwafer, boathouse; Lift, or groin must be set
bacK a minimum distance of f5';from-M area of ri ariari:access unless warred by me. (If you . p
wish to waive.the.sothack; you mustsiriltia[ the app aprlate blahl� below.)
do wish. to vraive. the 1 �tsetbaek requirement "
. I do not wish to waive the 15, setback requirement
(Property 0wner Intoriti tian). .. jAdjacent_Property Owner Information)
L Signature . p
z
,i rre $.
Print ar7y a Name Print or Type Name �. .
Ma�7i Addres M. ailing Address ►--
Ctyf$fateip Cify/State1Zip ® o
7eleplidne �Fumber
Tejephone Number .. —'I • a . ��
Dute Date _.. .
7.�fZ'�
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNSTATEMENT 4 .i
1
I hereby certify that I �o�.vri' property adjacent toy' Z:. IC
_ Iamk4f Property Owners • . i '
property located at
� Ad�resa, -Lbt, Blo;:Road,on thf—:
. .. [[ �,�. ' • N.C. ••''` '
(Watterbddy� _
,;... - •.. (Cii�/['owa andtor C�ttnty)
Thy applicant has .despribe to ire,. as- shown below,`the. devalopmenfi proposed at the :above.
-,
locatiari.
-I- have- no-pti "ion to _this.proposal: '
have.objei ions tb this propas-1,
`.DESCRIPTION �1Nf1E�i DR�[Ih(INa 0ROPS�:DVLOPMEN'f:
(Iridlyld�ual proposing.deYe/opme�f:m�st A� 'in descrijdtlon below ar a#ach'a sate drat�irng) i
:. WAIVER SECTION
:. L'undarstaridaPiat;a • pier -dc'ek, hioorip it n s :breakvva}er, boathouse; lift, or groin must be set
baclt a r �inirrlum:distarice of fS' from'My" area of itipanari•:aecess unless warred by me. (If you ,
wish to walve.the.setback, you jinust it It. #h8 p Capri ite,blahk-below.).
' I db wiah, ta:vuaive. the 1 S'setaek requirement.
. I do'riot wish to waive the 15' setback'requirernent
Ad'ac�rit Property Owner Infor"mat! n)
(Pro -eo Owh6r, Inforr ( 1: P Y
Sighature .
n ,. a
print bt Type Name
print.. T Name n m • ,
?SShf i in Address
ityl$tate�ip.-.• _ .. • C�IStaf�lZip ® _o � ' '�.
line�lfwnber
Tiephotle Number .. • . - : � �..
✓' Z� : ' Date
(Revised 6118120f2) #

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