Temple, Johnny

H
AMA / DREDGE & FILL N2 71344 A B C D
GENERAL PERMIT Previous permit#
Clew -Modification ❑Complete Reissue Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality �f f j
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC les attached.
F i�t t
f 1 _ /+ Project Location: County i�/ .'
Pro`1
Applicant Name}
Address , r l " `c ✓ ✓� A // Street Address/ State Road/ L/otj#((s
V ;; � f/ v (
City. "'t ,.�.`; .i ,/l..*li;!'c:,/ f Stater -VA ZIP r�16 c✓i _ _ ,•- 1 �
Phone # ( ) Z!f 0' Mail, / Subdivision
Authorized Agent f ��( /� r ' City__ ZIP
CW y�" ` -r?*A -ES 1-1PTS Phone # ( ) wer Basin
1 t
Affected - OEA ❑ HHF ❑ IH ❑ UBA ❑ N!A.
AK(s): Adj. Wtr. Body nat man unkn
Pws:
Closest Maj. Wtr. Body
ORW: yes / no PNA yes / no
Type of Project/ Activity +-'
> f (Scale: A,/`
Pier (dock) Ii
Fixed Platfor
Floating Plat]
Finger pier(s
Groin length
numbe
Bulkhead/ Ri
avg dis
max di
Basin, chann
cubic }
Boat ramp
Boathouse/
Beach Bulld
Other
Shoreline L
SAV:
Moratoriun
Photos:
Waiver Att;
A building permit may be required by: _
( Note Local Planning Jurisdiction)
Notes/ Special Conditions
t or Appli t Pri ted Name
Signature Please read compliance statement on back of permit
� eEE
PermitOffic 's Printed Name t
Signature t
iJ it`di�
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:
L 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/ 1-888ARCOAST
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

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:'a�
Mailing Address. -
Phone Number. t+) 75"I 3�c` - ���u Cam) 757 7C -664j
Email Address:
I certify that I have authorized RR�S ''`' Gc>
Agent / Contractor F3+u.y Kkm iS
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: Cam'
at my property located at t "Cl V DRI
in County.
I 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. �T
/11,
Property Owner Information:
d �
�--ture
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Print or Type Name
FIAC4E: 2z c
'Title
d- 12 1 1 Zvi ;8
Date
This certification is valid through I 1 3i 1 7—Ce?,
'l3

ADJACENT RIPARIAN PROPERTY OWN
ER
STATEMENT FOR CAMA MINOR PERMITS
I hereby certify that I own property adjacent to
(Name of Property Owner)
property located at�'��
Address, Lot, Block, Road, etc.)
bA`s� R�'vcR (Waterbody) in �jl `� _0_Lz' CL N.C.
on 1r1N1 i (Town and/or County)
He has described to me as shown 51v SSE c_iA
he is proposing at that location, and, i nave no objections to his proposal.
(APPLICATION AND DRAWING OF PROPOSED DEVELOPMENT ATTACHED)
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Print 6r Type Name
Telephone Number
11
Date
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ADJACENT RIPARIAN PROPERTY OWNER
STATEMENT FOR CAMA MINOR PERMITS
I hereby certify that I own property adjacent to •-S3"' ! L-y,OV: 3 's
(Name of Property Owner)
property located at —66 ► `.Jo13Tvk ��- `�7 P-7 Vp'
Address, Lot, Block, Road, etc.)
on YJN%TL CxA^ RyycR , in Qi-0-�-'1-0i. Cam.='J-r j N.C.
(Waterbody) (Town and/or County)
He has described to me as shown it i Ski" i �3C-t�'L ►*Z�. VzK '
he is proposing at that location, and, i nave no objections to his proposal.
(APPLICATION AND DRAWING OF PROPOSED DEVELOPMENT ATTACHED)
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7Sii�gnat e
Print or Type Name
Telephone Number
D ate
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