Sibley, Alton

DCAMA /-El DREDGE & FILL No 71369 A B C D
GENERAL PERMIT Previous permit#
❑New'Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality nf..
�, I I Jam;
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
7..Rules attached.
_
Applicant Name Project Location: County ' f
Address Street Address/ State Road/ Lot #(s)—
City
State' ZIP
Phone # ( ) E-Mail
Authorized Agent
❑ cW
D EW _3 PTA
Affected
❑ OEA
❑ HHF ❑ IH
AEC(s):
❑ PWS:
ORW:
ves / no
PNA yes / n
Subdivision
City ZIP _
-- ❑ ES ,aPTS Phone # ( ) , River Basin
❑ USA ❑ N/A Adj. Wtr. Body ?' t � n tJJ m/an unkn
/ , V T
Closest Maj. Wtr. Body
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mom
MEN
WON
MIS
Small
a
ME
0
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a
No
ME
No
No
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ME
ME
ME
ME
No
No
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0
No
LINE
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Agent or,Applicant Printed Name � �`
Sin t e Plepr read compliance statement on bac f permit**
r 5-1
Application Fee(s) Check #
Permit Officer's Printed Nam
Signatur ' t
Issuin¢ 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 7/06/ 17

I hereby certify that I own property adjacent to
property located at
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(Name Hof P
1")f4 Kc,"
Ow
$s
Add ess, Lot, Block, Pad, etc. )
on %� t % Aj P e V ( , in �1-e r,r 7 71 , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
IY'G— 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 tie/ow or attach a site drawing)

I hereby certify that I own property adjacent to
property located at / --A / 1 In' 4- -' i
OWNER STATEMENT
.`L
(Name,of Pronorty Own
I^Ifl K t ,0q-
's
r--, (Addless, Lot, Block, � pad, etc.)
on � /� �,� / P f 1' , in i)7-e- rr I U , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
lo9ption.
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 blelow or attach a site drawing)
J�c
.� Y{6 L
X'C
WAIVER SECTION %1
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. 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 Information)
Si t tn
/_ V /", Y
Print or Type Name
Mailing Addresss�..
City/State/Zip
Telephone Number / email address --
--- ��' _j"b 7%
Date L{-
(A jacent Property Owner Information)
iqxY
nature*
ty')4 ji & e, ti
Print or Type Name
//) Sr /-_.ee-/ r-L-5
�1L'Ts
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Date *
address
(Revised Aug. 2014)