Churchill, Raymond

CAMA / DREDGE & FILL No. 73209 A
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 I SA NCAC
Applicant Name Project Location: County
Address Street Address/ State Road/ Lot #(s)
CityState ZIP
Phone # ( ) E-Mail Subdivision
Rules attached.
B C D
Authorized Agent City - _ ZIP
Affected
CW EW ElPTA ❑ ES 0 PTS Phone # ( ) _ River Basin
_ — -
AEC(s): OEA HHF C IH ❑ UBA ❑ N/A Adj. Wtr. Body _(nat
PWS:
ORW: yes / no PNA yes / no Closest Maj. Wtr. Body -_—
Type of Project/ Activity
man /unkn)
,( I(Scale:) k' )
Pier (dock) length
_
Fixed Platform(s)
I
FloatingPlatform(s)
Fingerpier(s)
�-
Groin length
number
Bulkhead/ Ripra , length
I
avg distance offshore
_
_
4`
W
t
7
max distance offshore_
-
Basin, channel
cubic yards ' y
Boat ramp
Boathouse/ Boatlift
—
— --
i
Y- {
Beach Bulldozing
Other
"
i
i
Shoreline Length
SAV: not sure yes rio '
iq
Moratorium: n/a yes no
Photos: no
yes
t
Waiver Attached: yes no
on
A building permit may be required by: c ` " '};t
See note on back
regarding River Basin rules.
( Note Local Planning jurisdiction)
Notes/ Special Conditions
- own ,o 1
Agent or Applicant Printed Name
Signature "Please read compliance statement on back of permit"
o
Application Fee(s) Check #
t
Permit Officer's Printed Name
r -
Signature r
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 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 howto complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-8884RCOAST
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)
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)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: _ ►� C (� h , 1 I
Mailing Address: �1 tv w ¢ l c L-,,yz
Phone Number:
Email Address:
I certify that I have authorized
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at /
in C� County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
Permit application.
Property Owner Information:
—4�ii
ignature
V — C l�K
Pfint or Type Name
Title
Date
This certification is valid through / /