Chadwick & Assoc

CAMA / DREDGE & FILL No. 73128 A B C D
lCrKIERAI 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 I SA NCAC
Rules attached.
Applicant Name __ Project Location: County_
Address Street Address/ State Road/ Lot #(s)
City - - - State ZIP
Phone # ( ) E-Mail __ Subdivision
Authorized Agent City ZIP
-' CW EW ❑ PTA ElES ElPTS Phone # (_ ) River Basin
Affected
AEC(s): OEA ❑ HHF E1 IH ❑ USA El N/A Adj. Wtr. Body
- -
PWS:
ORW: yes / no PNA yes / no Closest Maj. Wtr. Body
Type of Project/ Activity
Pier (dock) lei
Fixed Platforn
Floating Platfc
Finger pier(s)_
Groin length
number
Bulkhead/ Rip
avg distz
max disc
Basin, channe
cubic ya
Boat ramp _
Boathouse/ B
Beach Bulldo;
Other
Shoreline Ler
SAV: r
Moratorium:
Photos:
WaiverAttac
--
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"
Application Fee(s) Check #
_ jnat /man unkn
(Scale: ) I
❑ See note on back regarding River Basin rules.
Permit Officer's Printed Name
Signature
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:
�I 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 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/ I-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

or L4L. 7"/k
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Hurricane Florence Repair Request Form
/ e
Name of Property owner:
Date:
Address of Property:
Mailing Address (If different than above :
Telephone Number: C-��}
Repairs due to hurricane Florence will be madam the existing footprint of the previous permitted structure.
Signature:
***Please note that if the structure is within the 15' setback of the riparian line and/or any CRIM
gAjy��(nust
have the adjacent riparian property owner notification/waiver form signed.
03A13038