Leary, Mike

-LAMA / ❑' DREDGE & FILL NQ 71321 A B C) D
r. GENERAL PERMIT Previous permit#
i J ew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
-7 and the Coastal Resources mmission in an area of environmental concern pursuant to 15A NCAC t-PIMes attached.
- Project Location: County ` w
Applicant Name_;Alit
Address
�aE % Street Address/ State Roa Lot # s)
City -- / State ZIP��"'
Phone # JV330 -7 �U-? E-Mai Subdivision
,. i ,, City ZIP �3
Authorized Agent `
❑ Cyy r i p ❑ ES ❑ PTS Phone # ( ) �ver B,a{sin -1J
Affected ❑ OIEA ❑ HHF ❑ IH ❑ UBA ❑ N/A 1.,,.9A.n.✓ man unkn
AEC(s): Adj. Wtr. Body
❑ PWS:
Closest Maj. Wtr. Body `� t� r
ORW: yes / no PNA yes rho
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s) y �-
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
Moratorium: n/a yes rw I
Photos: yes t
0
Waiver Attached: OS
no
( ✓ �/ �,
A building permit may be required by:
�i
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
Sig a "Please read compliance statement on back of permit"
Application Fee(s) Check #
(Scale: )
❑ See note on back regarding River Basin rules.
r,
r l
Signature,.,,
Issuing Date xpiration 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/ 1-888-411COAST
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

JP Jackson Contracting
2527642891 p1
J,4, 647-333D
AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION a1�-
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
-3 36-- -15Z17
YY ri 1�2
Agent /Contractor
1. C QYY)
to act on my behalf, for the purpose of applying for and obtaining all CAM
necessary for the following proposed dA permits
development: /
at 'IV property located at �6
ti County.
I furthermore certify that l am authorized to grant, and do in fact grant Division of Coastal Management staff, the Local Permit Officer and their Permission to
"' the aforementioned lands in connection with evaluating information related
to enter
,'j*nit application. ed to this
Property Owner Information:
Title
Date
This certification is valid through _I

JP Jackson Contracting
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
;ri ,s
1 hereby certify that I own property adjacent to�-1 P O er)
/1 A r (Name of Pro erty
property 'ocated at (Address, Lot, Bock, Road, etc.) N.C.
on (Waterbody) in - (City/Town andlor County)
The app
lica t has described to me, as shown below, the development proposed at the above
locatio .
I have no objection to this proposal.
have objections to this proposal.
.�ucw1T
DESCRIPTIOI
(Individual proposing de
'ING OF PROPOSEu lJtvr-L-"
Fill in description below or attach a site
drawing)
WAIVER SECTION groin
I understand that a pier, dock, mooring pilings, boat ramp, breakv✓@ter, boathouse, lift, or
must be set back a minimum distance of 15' from My area of rip3fl8rl access the appropriate blank below.)
me. (If you wish to viunless `valved y
aive the setback, you must initial
LLI do wish to waive the 15' setback requirement.
I do not wish,.to waive the 15' setback requirement.
(Propert Owner lnf rmation)
Sim naJ�u �.
Print or YP'3 N(s(r 4 ,4,b [ .,f
MailinqA ddress , r T ��
Gift'/S ate.2io
Teie�o,e N/�er/emai, address
Date
"V21ic for one calendar year after signature
(Adjac nt Prop r<y �w�.�...
i
Sign re
Print Tyo
Maiii�g Aoddress�
Gity/state2tp
Telephone N ber/email address
Daie*
(Revised Aug. 2014)

JP Jackson Contracting
2527642891
p.3
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
, iYt Q � ,
I hereby certify that I own property adjacent to { 1 s Name of Property O er)
h nr
property located at
on
(Waterbody)
(Address, Lot, B ock, Road, etc.) N.C.
in /I1'iF /) [: j7 &
(City/Town and/or County)
The applicant has described to me: as shown below, the development proposed at the above
locatio . 0
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, 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.
(Prop y Owner nformation) (Adjacent Property Owner Information)
(2
Sian �
Signatt
Print or Type i ame
Print � TPe m�e q L 1 lCf
Mailin ddress MailVddress
g&r"e r«Ord Ale �
City/S-tatelZip
CitylStatelZip
3 p
Tele hone Num�er / email address
Telephone Numb / email address � I
Date Dace
(Revised Aug. 2014)
"Valid for one calendar year after signature`