Rouse, David

E�CAMA / ❑ DREDGE & FILL N_ 70495 A B (,C D
C�EN,E L PERMIT "` Previous permit # ti
New dific tin omplete Reissue ❑Partial Reiss►ie + Date previous permit issued
'X /
As authorized by the State o ma, Department of Environmental Quality ,
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC uWs att
Project Location: County -
Applicant
Name
Address (� i Street Address/ State Road/ Lot
City State ZIP
Subdivision
Phone # s
r
E Mail
Z y y + a<
Authorized Agent.y `'t City IP
❑ CW ❑ EW ❑ PTA �Es [IPTS Phone # (_ ).' River Basin
Affected ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
AEC(s): Adj. Wtr. Body gnat /man /unkn)
❑ PWS:
Closest Maj. Wtr. Body --
Tsui.-- i .... PNIA vac / no
Type of Project/ Activity
Pier (dock) length_
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ Rip'iap length; " -L
avg distance offshore_
max distance offshore
Basin, channel
cubic yards ---�
Boat ramp
Beach dozing'""" _ M
Shoreline Length } -�
SAV: not sure yes + no
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no
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)
f
(Scale: I '
i=... , )
See note on back regarding River Basin rules.
PermitOfficer's Printed Name
Signature
Check # 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
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
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 7106117

N
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ,� (Name of Property Owner)
J�J
property located at sm, 1-
SWIIIJ I . (Address,Lot Block Road etc. N.C.
on. -,in
(Waterbody) (CItylTown and/or County)
The appllicqo has described to me, as shown below, the development proposed at the above
t
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)
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 th setback, you must initial the appropriate blank below.)
­777, I do wish to waive the 15' setback requirement.
I do not wish to waive the IS' setback requirement.
(Property Owner -tAformation)
Sign Cure
tits20vi-e
Print or Type Name
513.
Mailing Adoress i
t4V), X, i -en 1-f
citylstatelzip
Telephone Number
-7,') 9
Date
p
(Adjacent Property Owner Information)
Signatvre
L 1" 4
Print or Type Name I
Mailing Address f f
civstetelzip
A) C � f
Telephone Number
Dole
(Revised 611W012)

I f d 4 4J Fj Maxwell Builders, Inc. /000 1
AQJACEN'r RM& PROPERTY OWNER IT JemENT
AL
I hereby car* that I own pMpgrty acam" to :PAVI p Ruate
(Name of Pro pmw 5=)
PftP*AYlQ4S%delf -zPd'4 eh 9.
("OWN. 110C ft 4
N.C.
(Cfttffawn mmUor cotmim)
The OPPH demftetf to na, m shown Wow, the 4*Vo*pmnnt prapastO at the ebmt
Nava no oWcoorl jq Mk prop*".
hwm *OCCOM to this PMp"
UON A- WOCM C"tAVRNQ CM PMWMD DeveLopacgmT
O'd1viduM PmP*64W davokpqMt roust Win des Amlow or oftch & &* draWno
WAIVER AIR93M
I UndOrStOIntl that a plet, dock, MOOft PftP, bmekwater, boOmm Ift or groin must be go
bw* a minimum 'fistm" Of IV I" MY ar0a Of dpaftn access unWm walvo by me. (if you
aW1011-to 38"mck4 You Must is tho SoMpflots blank below.)
y\1 #o VAsh to waive a0thsalt ratitOmment
I do netvibn towleme the Is Vottmax requirement
- - - -- - -1 =— ft
0
O&A�K **,-W.Z - 7see -fj:FA-
VP68%
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AGENT AUTHORIZATION FOR LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Zolito Foo-re_
Mailing Address-.
Phone Number:
Email Address:
I certify that I have authorized
/V6
2s2, - 3 y I - —70 1� 3
Oo,-,je Co am4jl 06-
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
eU),41-e - E'PP ("'o
at my property located at 20 2 Syn, It-, f
in - 0 dtzl7r��- County.
I 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 OV81Uatil7g information related to this
permit application.
Property Owner'Information:
f Signature
Ldj,,-1,b 20 Lis e__
Print or Type Name
io - —
Title
Date
This certification is valid through � I � 1 20 19
j

CARTERET COUNTY HEALTH DEPARTMENT
Environmental Health Division
3820 A Bridges Street
Morehead City, NC 28557
Phone [phone] Fax [phone]
OWNER'S STATEMENT
TO: The Environmental Health Division
SUBJECT: Authorisation for Representation as Agent for Owner and Permission to Access Property
i, Avt1z uuP rin . hereby authorize 2tg,., hp ,1��gr ¢,wsto� n� to act
as my agent in the process of application for an on -site wastewater system pern it o� well
permit for the property listed below:
(Real Estate Agents or other agents contracted to act as property representatives shall provide a copy
of the signed contract verifying owner has acknowledged their representation of below property).
Location: Z ak 5�,. ti, s`� . PIDN # 037512 bT -_?3000QD
In addition to the above, the Environmental Health Division has my permission to access the above
listed property.
Should you need additional information, please contact:
Owner's Name._ Au4n Ko. S '
Address: S' 3 T¢, .r LN
city �dt1r tit,, 1 state. aJ C.. --- Zip. U
Phone: Z.57-.. 3Y1- -7 vg'?
Email: 003-c- e a' r
Owner's Signature: Dater ��

N
N
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to �D6U11) 20LJSf Is
i '.� (Name of Property Owner)
property located at d� �'� s ..t.f,
(Address, Lot, lock Road etc.
on SwAJ� inI�g��cr�c N.C.
(Waterbody) (Cttyrrown and/or County)
The appfic3pthas described to me, as shown below, the development proposed at the above
locatio
I have no abjection 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)
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 th 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.
(Prope rty Owne rmation) (Adjacent Property Owner Information)
R
t hU=
Si ure Signature
of L/nvD4 (' P eDAV lb tf
Print or Type Name Print or Type Name l�
.,Sl 3 s� LIV 2 o U S'm
Mailing Ad5ress Mailing Address � i�PAc�
W,1"ttrt(�' & APAI Ic
CitylStaip ' GitylSt tfetZlp
U A) C 2
Telephona Number Telephone Number
2s��_ 74 93
Lute
Dare
(Revised 8 0012)

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Page:1/1
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3
APACE Y EKIPAR16N PROPERTY GUNNER STATEMENT
I hereby ceriiry that i own property adjacent to �A w b RR _Vse_ s
n. „ t) .-) (name of Property Owner)
property located at atJbc. JeA,ten_ 01.
{Address
on ic.�+ �sN _ in
(Waterbody)
The opplIc!pt has descrlhed to me, as shown balow. the develoPmant proposed st the above
iocatio
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWNGi OF PROPOSE13 DE'Ve OPMENT
(individual proposing development must fiA in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15from my area of riparian access unless waived by me. (if you
wish -to waive th setback, you mutt initial the appropriate }clank below.)
i do wish to waive the 16 saftok requiremmwL
- I do not wish to waive the 16 sewaicK requirement,
(Property Ow Information) (Adjacent Property Owner Information)
SipAaIwO Signature ,
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!liegito VERNON WAYNE JOHNSQN
Ciosur d Surveyor
1!:, L-1C9b / fNGiNEER1NG loSltrarltid�eo.v«
This nap is not for recording .

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itau�pell
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hereby ♦'. i!that I own •roperty .. ter. •" d
(NAMS Of Property OAWW)
•&+ _ •f
and/or'r'. y
The aWcoothasdescribed to - shown below, the development proposed above
I have obJeoWne to this proposal.
WAM- SECTION
f understand that a pier, dock, mooft pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 35` f m my area of riparian access unless waived by me. (if you
wish -to waive sett you must initial to appropriate blank below.)
i do wish to waive the t5' setback requirement
t do not with to waive the 151 setback requirement.
®�■laa•IOIIi■■ ■ li�ii��
(Pro aetlon) (A,cUa cent Property Owner inforen*Mon)
inaft"
T)Au ib Povs-eY-J".04 06*wo
Print or T Nema Print or Name
LZA
lYt tile
Meft �
AN t G
Telephone Ntmiber Telephone Number
(Revised M WO12)

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VERNON WAYNE JOHNSON
Ciasur e5i t d Surveyor i 1143lIaswlK*I Orin
!Mr'Uj.- G-1496 OAT
f ENGINE MING p�t�ipkw_N.G,�Tgp3 SURVEYING
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CiOsuz ei t d Surveyor
f j/ VERN©N WAYNE J011:N90N
--lfAOP,UJ )- L-1496
3tOSt�aasR' peiK
ENGINEERING �
(aAT -�- ZT803 3lS R V E Y t N G
Th�3 s nap is itiat for recording.
{ f419S 772-tifj4p

1 hWebY c8rffY that I own property arrkac em to
PAY Ioad*d apt I-;- J�rn c •I< (Name W Property Own-- s
on SrA,., .. (+Address, Lot, jshmkRoad eta.j .—
t.... �r in ! ►c. P/�G N.C.
(Watarl ody� (CitYlTOM andkw CountO
The apo has d0sclibed to me, as shown below, the development proposed at the abov:
rrr R-i 41
•..
hN
(1�
y i
I understand that a WAtYII=R � tON
back a minimum distance g ft IAWV$, k�taater, boathouse, tiff, or groin must be set
back
waive MY area of riparian aoms Unless, watVM by me. (If you
You must initial em appropriate blank below.)
I do wish to waive the 19 setback reguiremer>t.
I dQ not with to waive the IS, setback requinsme &
(pro °r'} ( xcer�t PMPerty Clwna►r tntarmaon)
Print or T Name J
rr LN Print or Toe Name
G U
c chl%e ' j f4
Tetephotxe AU*er
2�S _ 2tu _ --JA a. 7'tsphone Number
Doe
(Revised M WO12)