Southerland, Warren

�CAMA / DREDGE & FILL r y 2/ 0497 A B C D
GEN l PERMIT 1� Previous permit #
-New Mgdificatio Co plete Reissue Partial Reissue Date previous permit issued
As authorized by the Stoe"Nol'Cariolir., Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
Rules attached.
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Applicant Name-•- Project Location: County _
Street Address/ State Road/ Lot # s
Address (� ►'� ( )
City- — State- _ ZIP
Phone # ( )_ ;;J'i E-Mail
Authorized Agent j
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Affected
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AEC(s):
❑ PWS:
ORW: yes / no PNA yes / no
Subdivision
City
Phone # (_ )
Adj. Wtr. Body
Closest Maj. Wtr. Body -
ZIP
River Basin
(nat /man /unkn)
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Agent or Applicant Printed Name
Signature "Please read compliances tement on back of permit"
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Permit Officer's Printed Name-...__._.w .._ --
Signature
Application Fee(s) 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 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
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)
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)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/ 17

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ter �,��� .� !{ s
,( / (Na of Property Owner)
property located at 16 U J /V d�� G 7 U
� o (Address, Lot, lock,Az
oad etc
,J
on _ in �� , N.C.
(Waterbody) (City/To (n and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc
� 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)
L�r�� er C
\ WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwa r, 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 Inf ation) (Adjacent Property Owner Information)
,ivlti
Si ature Sig ture
rnllvr-ems _ eti � -- C f S
Print or Type Name _ Print or T pe Name
J n Ids r O
ailing Address Mailing Address W
City elip,
Ct� 3 telZ
t p %�, . S �� D V
Telephon Numb / email address Telephone Number / email address
Date Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature*

lb
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to f��� .) e�-�-d�k e i- I e-41_'s
r (Na e f Property Owner)
property located at �6 D �wNr�-S Aim- /v ��C 2kS'7y
(Address, Lot Block, R a et )
on g0t—i - 5;- A-W , in 'e ✓ N.C.
(Waterbody) (City own and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc i
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)
�afe5
, e4
Ly
WAIVER SECTION
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.
(Pro rty Owner Information)
t nature
Print or�ype Name
Mailing Add ss C- 2�-5? O
ity/State ip
c9-06y—S'��f
Telephone Number / email address
Date
*Valid for one calendar year after signature*
(Adjacent Property Owner Information)
Sign e
b' jio,�( e w-
Print or Txp+e Name IV
Z 2 3 �t AXLC � A.i L
_ x4
a'ling Address
00
C
CY52lStat /Z;� I 9�'Y
W
W
N
C
U
fl
Telephone Number / email address
Cq
Date*
V
(Revised Aug. 2014)

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Applying A) �� `'L /'' A.)p y Owner for Permit. ��
� 1
Mailing address:
G %-./ 4,4, j tA--Y
A/� �� NG' �95 av
Telephone Number: !Y / 9- � �- 2 S 41 �
I certify that I have authorized KM� A,S Z-,4tAj('C-*J C e (agenticontractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
,/, Anecessary for the proposed development of / N �ol lliN� cs Pg we, `/ T o �
at my property located at G a 0 w
This certification is valid through Zvi'- 1,5:- (date).
(Property Owner Information)
t✓ �
Signature
f" e-1v
Print or Type Name
N,e�'
Title, co. owner or trustee for property
V /; fly
Date
�1q-66q-'5-g9L(
Telephone Number
Email Address

I hereby certify that I own property adjacent to _ ),4
(Name of Property Owner)
property located at �/ © Gt a, t b--Jy11-
(Address, Lot,)3lock, Road ,etc.)
on So r ,tea ,� - - in , N.C.
(Waterbody) City own and/or Coun )
T ap 'ant has described to me, as shown below, the development proposed at the above
tion.
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)
�'Ot"
JV
4e 1 re
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, brea ater, 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 Own`Inormation)
I 1 / IAJ1k Y V''tr-
Print or Type
Date
*Valid for one calendar year after signature*
(Adjacent Property Owner Information)
i�atu e
Print or Type Name
v
g ddres�
rC-
City/State,Zip
Telephone umber/ mail address
Date* RECEIVED
(Revised Aug. 2014) JUL 18 2018
DCM-MHD CITY

CERTIFIED MAIL • RETLIRN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONNVAIVER FORM
Name of Property Owner: s ,
6 D `J�G�-�.... c c o �ounty)
c Z a 7Address of Property: (Lot or Street #, Street or Road, Ci
Agent's Name #.
J,� e Mailing Address:
Agent's phone #:
Z�S-3 I
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described e as [h dimensihe onsamached ust bedrrovidedhwith this letter.
they are
osing. A descriptio
ave no objections to this proposal. ---I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within c0days of receipt of oasta/mana ement nethis
t/web/cm/staff-t"st ninformation
or by calling ? 888-4 Coffices
OAST.
ns
availableathtt cow
No res onse is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift must
be set back a minimum distance of 15' from my area of riparian access unless waived by me. (If
you wish to, yvaive 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 Ow r Information) �� (Riparian f roperty Owner Information)
Signature S gnature
Lo
Print or Type Name
Print or Type Name
Mailing Address
Mailing Address
CitylStafelZip
ity/State p
Telephone Number/Email Address
Telephone Number / Email Address
3 2/13
Date Date (Revised Aug. 2014)
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