Gammon, Rick

CCAMA / DREDGE & FILL NO. 73123 A B C D
r. GENERAL PERMIT Previous permit #
DNew ❑Modification ❑Complete Reissue El 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 Y
❑ ules attached.
Project Location: County -
Address Applicant Name -
Address / Street Address/ State Road/ Lot #(s)
City State/'/( ZIP-
' � Subdivision
Phone # ( ) � � ' E-Mail - -
Authorized Agent %" ` 'City -'' ZIP" -
Affected CW ❑ EW ❑ PTA ❑ ES ❑ PTS Phone # ( ) River Basin —
OEA HHF ❑ IH ❑ UBA ❑ N/A
AEC(s): Adj. Wtr. Body5 ' ` `" __ nat /man_/unkn)
❑ PWS:
ORW: yes / no PNA yes / no Closest Maj. Wtr. Body - --- -
Agent or Applicant Printed Name
Sign�XFe Please read compliance statement on back of permit"
Application Fee(s) Check #
Permit Officer's°atinted Nam, --- w -
Signature
Issuing D to % 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-1 Tar - Pamlico River Basin Buffer Rules Other:
J 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/ 1-888-4RCOAST
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)
w-
Revised 7/06/ 17

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: 1 \ f C t e�Ivt/Kdl
Address of Property:
Agent's Name #:
Agent's phone #:
(Lot or Street #, Street or Road, City & County)
Mailing Address:
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. Adse�iljdonor,.dr"avvmawithdiinensions rn'ust be provitled withh�sdeter.
I have 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 10 days of receipt of this notice. Correspondence should be mailed to 400
Commerce Ave., Morehead City, NC, 28557. DCM representatives can also be contacted at (252) 808-
2808. No response 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, 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 erty Owner nformation)
�.� Signature
Qom' ��3,,PrType Name
� t
Mailing Address
'rr C. �-S
.. / tate2ip
Telephone Number
(Adjacent Prop rty O ner Information)
�.f n
Xignature
Print or Type Name
-3406'
Mailing Address
AwG4, M-
City/State2ip
Telephone Number
Date
Revised 611812012

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: ! C
Address of Property:
Agent's Name #:
Agent's phone #:
(Lot or Street #, Street or Road, City & County)
Mailing Address:
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. Adsenpt�onor,=drawmgww�th�.dmerisons,rn`ust beiorav�detl with fhr�lettr
I have 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 10 days of receipt of this notice. Correspondence should be mailed to 400
Commerce Ave., Morehead City, NC, 28557. DCM representatives can also be contacted at (252) 808-
2808. No response 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, 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.
(Property Owner Information)
T C,
Sig/nature
Print or Type Name
Mailing Address
City/State/Zip
,Z �� , Sz 3
Telephone Number
l C i0 tl�
Date
(Adjacent Property Owner 1 ormation)
Signature
1�1C2_,
Print or Type Name
Mailing Address
E wxe,(Y�d Ts A) Se3 S�
City/State2ip
elL0 - 3 1'3
Telephone Number
T//
Date
Revised 611812012

GrAMMON9 HOWARD & ZESZOTARSKIg PEEC
THE WATER TOWER BUILDING
115vi WEST MORGAN STREET
RALEIGH, NORTH CAROLINA 27601
[phone]
W W W.GHZ-LAW.COM
JOSEPH E. ZESZOTARSKI, JR.
JOSHUA B. HOWARD
RICHARD T. GAMMON (OF COUNSEL
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