Dempsey, Dan

❑ CAMA / ❑ DREDGE & FILL NO. 73279 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
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
[Rules attached.
Applicant Name_ Project Location County
Address
City
Phone # (_ )
Authorized Agent
Affected ❑ CW
AEC(s): ❑ OEA
❑ PWS:
ORW: yes / no
Street Address/ State Road/ Lot #(s)
State ZIP _
E-Mail
EW ❑ PTA ❑ ES ❑ PTS
HHF EIH ❑ UBA ❑ N/A
PNA yes / no
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s)
Floating Platform(s) ..
Finger pier(s) l '
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
Subdivision
City ZIP
Phone # (_ _) River Basin
Adj. Wtr. Body-----, _ (nat /man /unkn)
Closest Maj. Wtr. Body —
Shoreline Length
SAV: not sure yes no (- -
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no
A building permit may be required by.
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
(Scale:
❑ See note on back regarding River Basin rules.
Permit Officer's Printed Name
Signature
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:
Tar- Pamlico River Basin Buffer RulesI 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 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/ 1-888ARCOAST 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 7106117

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to ,Oo,%J 's
(Name of Property Owner)
property located at z<*9`f
(Address, Lot, Block, Road, etc.)
on /��w�'�� % ��2 �K_ , in f1,"AgAl N.C.
(Waterbody) (City/Town and/or County)
The applic nt has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVEL
(Individual proposing development must fill in description below , r attach a site drawing
WAIVER SECTION
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.)
AI do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
/.�v-✓ �Jr sue%/"c= ��
Print or Type Name
Mailing Address
City/State/Zip
33,t<'- Z,..-,ZZT -
Telephone Number
/43 -- /z -- "?-
Date
(Adjacent Property Owner Information)
J, C
Sig nature
Print or Type Name
Mailing Address
,e�o , va
Cit State/Zip
Telephone Number
Date
(Revised 611812012)

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