Merrill, Richard

CAMA / P DREDGE & FILL No. 73126 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
Address
City
Phone # (__)
Authorized Agent
Affected ❑ Cw
AEC(s): ❑ OEA
❑ PWS:
ORW: yes / no
State ZIP
E-Mail
❑ EW ❑ PTA ❑ ES I] PTS
❑ HHF E IH ❑ UBA ❑ N/A
PNA yes / no
I Type of Project/ Activity
Pier (dock) length ' t f F
f
Fixed Platform(s)
Floating Platform(s) f
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length_
avg distance offshore
max distance offshore "r
Basin. channel
cubic yards
Boat ramp ; y
Boathouse/ Boatlift j t
Beach Bulldozing
Other, 1
Shoreline Length
SAV: not sure yes no
Moratorium: n/a yes no
Photos: ye n
� I r--
Waiver Attached: yes `- o
A building permit may be required by:
( Note Local Planning Jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Na
Sign(pt rep * Please read coahpliance statement on back of permit
VCN
'T -�
e�
Application Fee(s) Check #
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP
Phone # ( ) _ River Basin
Adj. Wtr. Body (rat /man /unkn)
Closest Maj. Wtr. Body ___. -_-_
(Scale:` )
y �5
�I See note on back regarding River Basin rules.
Permit Officer's Printed Name -�
Signatur
7b-� o`
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, certifythat 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 L_- Other:
E 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 Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ 1-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves: Carteret, Craven, Onslow - (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet- and Pamlico Tyrrell and Washington Counties)
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)
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)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/ 17

N.C. DIVISION OF COASTAL NAG 117",
AGENT AU=TH,0F.JZA i0','1l f YDR a
Date
-tif Property Owner Applying for Permit:
Mailing Address:
y03 lvkve AweoZjle 6/-
/v/&-k) NC zss-6o
RECEIVED
OCT 17 2018
DCM-MHD C17'y
I certify that I have authorized (agent) 7-01yl to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) �U wGL ,
at (my property located at)
This certification is valid thru (date) /2 / 1 ZZ9
Property Owner Signature Date
S7rUA'4p
;j19 Mk- F:o.7, pb4ol

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID:
ECEIVED
STREET ADDRESS: OCT 72018
141 c Loc?�Z , rv< 2 W ,5 j� z DCM-MHO C1Ty
Please print: �
Property Owner: / rC/,�.91'U ��- !L�i%�2 G✓_
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
T o�'A' G �RG.a•��s � ,�2� �/ y-� ! 88.E
/ 6 Z- �ct_►JLz 5 of
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
Telephone:
2.5 z ",VZ) �Z
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Auth rized Signature Authorized Signature
Date: /G ,�&
Date: