Stacy FWBC

❑ CAMA / ❑ DREDGE & FILL Na 70478 A B "C D
r. GENERAL PERMIT Previous permit#
❑Nzw ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality i f
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
H,les attached.
Applicant Name t Project Location: County
Address Street Address/ State Road/ Lot #(s)
City State ^,! ZIP _.
Phone # O E-Mail
Authorized Agent
Affected ❑ CW ❑EW ❑fTA LIES ❑ PTS
[IOEA ElHHF ElIH ❑ 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
Boathouse/ Boatlift
Beach
Other
Shoreline Length
SAV: not sure yes . no,
Moratorium: n/a yes
Photos: yes
Waiver Attached: yes
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
or Applicant Printed Name
s .i "� .
Signature Please read compliance statement on back of permit
Application Fee(s) Check #
Subdivision
City ZIP
Phone # O -River Basin
Adj. Wtr. Body' (nat man unkn
Closest Maj. Wtr. Body ` ~ I'. -
(Scale: s` i �' )
❑ See note on back regarding River Basin rules.
Lr'
Permit Officer's, Printed Name
� ' t
Signature
Lk
Issuing bate I iratio ate

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 complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST
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

��6. Ps' ki I . wilejl III:
PWWA
I fI WRAMF-;.V- fill
Bevedy Eaves Perdue. Governor 48fm K Onsson, Okemr Oee fnonao. SeavWy
Date � • i _ i �,
Applicant Name
Mailing Address
Gke
Ica" that I have andmi od (fit) �t I`jd �� toad on my
behalf, for the purpose of apWug for =W obtainig alt CAMA Permits ■acuwy to
install or construct (activ*)
at (bcatim) � .((�
v t�Ls w -7 ss� y �.C,L
r
Signature
RECENED
MAY p g W0
j)CM_MHD CITY
400 Ccmneme Avenue. Mo el" Cky. WM Camino 2M7
Phone: 252-8 81 FAX: 252-247. M % k*wnet 1
M EVdOWFLV4Y1ffnm &VAG1onrm Of'jm—50%Rmerded%* .PMCwmm et Pam

AQJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Stacy Free Will Baptist Church .s
(Name of Property Owner)
property located at 1290 US Hwy 70 Stacy
on (Address, Lot, Block, Road, etc.)
Core Soundllis Creek , in Stacy Carteret County N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loca
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
i7 1vldual *Vpc ng develop must Nil In dss 4flf ;fnbelow or oftich a site drawing)
17D r
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 bEIVED
I do wish to waive the 16 setback requirement.
MAY 09? �
I do not wish to waive the IS' setback requirement.
( roperty Owner Inform ion) (Adjacent Property Owner Information)
Si ature / / Signa re*
Leon E. Peppers (Deacon(Treasurer) John Robinson
Print or Type Name Print or Type Name
1793 US Hwy 70 Stacy 111 Emilee Ln
Malting Address Mailing Address
Stacy, NC 28581 Stacy, NC 28581
City/State zip City/State2ip
[phone] [e-mail] 342-1713
Telephone Number / email address Telephone N mber / email address
May 03, 2018"�,
Date Date*
{Revised Aug. 2014}
*Valid for one calendar year after signature'

I hereby certify thirt I own property adjacent to Stacy Free Will Baptist Church
$
Property located at 1290 US Hwy 70 Stacy (Name of P ropsrty der)
on Core Sound/Willis Creek (Address, Lot, Block, Rout etm)
In Stacy Carteret County N.C.
(�) (CitylTown and/or County)
The applicant has descnbW to me, as shown below, the development Proposed at the ab m
location.
I have no objection to this proposal.
DESCANWOR DRAVANG OF PROPOSED DEVELOPMENT
(1ndVwdWi/ t a 1 df�ltaetr r }NI In below ors a."Vlb drawirr
l TD t
ZD f 5
I understand that a Pier, dodo, mooringbLAl10EB $900N
must be set back a minimum distance of 15 frao, boat
m Srea afathr,thouse, lift, or grolo
me. (ff you wish to waive the setback, Y riparian access unless waived by
you must initial the appropriate blank below.)
I do wish to waive the 16 setback requirement.
f do not wish to waive the 15 setback reouirerr
(rr0PWW owner l on)
i lure
Leon E. Peppers (DeaconlTreasurer)
PrW or Type Name
1793 US Hwy 7n Stacy
M8111179 Address
Stacy, NC 28581
cr1y/W1RWZ p
[phone] IpeppersCrhec rr com
Telephone Number / ema address
May 03 2018
Date
"Valid for one calendar year after signature°
��[lTitTe
David Livingston
PrW of Type Name
139 Masontown RD
MMM19 Address
Newport NC 28570
c�r/sr�te�2�p
1252) 223-4811
TelepitoP /email address
` C "-:
uare� v
i
RECEIVEO
_MAY 0 9 2018
)MHD CITy
(Revised Aug. 2014)