Core, Tammy

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--. CAMA / ❑ DREDGE & FILL ' 70500 A B `C" D
GENERAL PERMIT Previous permit #
[]New ❑Modification El Complete Reissue ❑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 ! :
f jtulesattached�.,�,
Applicant Name ! >' j f ii J Project Location: County ,?--" ' j, 1
Address r� f-2t„r - a , t ' Street Address/ State Road/ Lot #(s)
City State ZIP
Phone # ( ) E-Mail
Authorized gent'
Affected ❑ CW ) EW ,.Lt1 PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ElUBA ElN/A
❑ PWS:
ORW: yes / no PNA yes / 'no
Type of Project/ Activity
Pier (dock) length <"
Fixed Platform(s)
Floating Platform(s)
Finger pier(s) r
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore_
Basin, channel
cubic yards
Boat ramp
0
Boathouse/ Boatlift
Beach Bulldozing
Othert
r t
Shoreline Length'
-
SAV: not sure
yes no
Subdivision
City _ _ZIP___
a
Phone # ( ) River Basin f '-»
Adj. Wtr. Body_ (nat /man unkn
Closest Maj. Wtr. Body
Moratorium: n/a yes no t
Photos: yes no
Waiver Attached: yes no
A building permit may be required by:)�
( Note Local Planning jurisdiction) w
Notes/ Special Conditions t
Agent or Applicant Printed Name
Signature ** Please read compliance statement din back of permit
Application Fee(s) Chgck�#
r
(Scale: 0 )
❑ See note on back regarding River Basin rules.
Permit Officer's Printed Name f
Signature
Issuing Dat,4 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 howto complywith 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/ 1-888-4RCOAST 252-946-6481
Fax: [phone] 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
(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

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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
i+e ,de. "C/1, dL .3L-7 r�L,
Zj 2 41 5" 7- '31,5I
_��ce �� ,ifs>2. /t,.✓. e'c�;n'1
JL V `\No, Sv,�Cx� —,Q
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: lac,: t /, 6
at my property located at t 1 J ';e'ere- re ✓t : Pme ki-,if
in 6-fz.- -f County.
1 furthermore certify that 1 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 Injophation:
Signature
Print or Type Name
v . e"
Title
ate RECEIVED
MAY 1 7 ?018
This certification is valid through �i I t I i fS OCM-MHO CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to Jc:"�C J 's
(Name of Property Owner)
property located at 1 5 T;r m< <; k.
(Address, Lot, ¢lock, Road, etc.)
on a-�a Ca � , in r We k-.,otl sLc.-, es N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
iocatior�
�,�' (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)
Zz
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 the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
1/ I do not wish to waive the 15' setback requirement.
Print or Type Name
Mailing Address
ff e,,j, s .,, Xt " 73_S
Cibostatemp
Z'SZ . y se �10 �3
Telephon Number
i5(" % (b
Date
(Adjacent Property Owner Information)
114 To
JA
Si ' ature
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Print or Type Name
Mailintt..�4dd� ISs,� , fli �- `7'7v-`�
tt--11 Q
City/Stat i
Telephone Number
'7 n 1 cu,; 01 C3
Date
(Revised 611812012L�j�,

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 's
(Name of Property Owner)
property located at 1 � J Ttal.< C-I^.
(Address, Lot, Block, Road, etc.)
on A-� CG�k in P,&)e kaotl SI4tcc-S N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatio .
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)
5 3
Z Z
t
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 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.
pgn,ature
i
Print or Typ Name
/ 7d Y,, ,c c r � f
Mailing Address
/�4'^ N(-, J 7
City/State/Zip
Telephone Number
/S '4�1, /6
Date
(Adjacent
Print
�v-
Malfi Address
P�,s
City/State/Zip
Telephone Number f �G� 0 v%
Date
(Revised 6/18)2012)