Clifton, Ben

❑CAMA / ❑ DREDGE & FILL No. 73187 A B C D
GENE_ RAL 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 State
Phone # ( ) _.__ _ E-Mail
ZIP
Authorized Agent
Affected ❑ CW/ ❑ EW PTA C7 ES ❑ PTS
AEC(s): ElOEA ElHHF - IH ❑ UBA ElN/A
❑ PWS:
ORW: yes / no PNA yes / no
Agent or Applicant Printed Name
Signature "Please read compliance statement on back of permit"
Application Fee(s) Check #
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision
City _ ZIP --
Phone # (_ ) River Basin
Adj. Wtr. Body (nat /man /unk�
ty„P.
Closest Maj. Wtr. Body"
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, 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 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/ 1-888ARCOAST
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 LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address: -S ki i •l�`
Phone Number: sts A 5-
Email Address: b c � 1 w- r�� -e-- P,oi ` ccf 404 r-4s , c t 104
I certify that I have authorized rn `
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:c
�rr'i C vik L.
at my property located at i -i r, At t', v y'. s LDS -
in C t--rcw"r- County.
1 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:
6
Signature
sv t✓ C 1 f= Tom'
Print or Type Name
p ��-- RECEIVED
Title
N O V 0 2 2018
Date DCM-MHD CITY
This certification is valid through I l

2-1-4 L �t ��. T)
9v-A `61S �l b--r,,,

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to 1,5 E P 6 ) i -F ky CvJ s
("e of Property Owner)
property Iocated at 2� �" D I ni 4 1 S IJw Iy�
(Address, Lo Block, Road, etc.)
on 4 5v in s j-►:= KN o l O N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location./
V I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in descriptign below or attach a site drawing)
RECEIVED
NOV 02 2018
DCM-MHQ CITY
WAIVE 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.)
A�"o wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
nature
Print or Tye Name
_�I'Z7�� 1 �o►� r� 2�6d�
Tling Address
Q Ieif) k N-'�-
City/State/Zip
1t4i 191
Telephone Number
Date
(Adj cent Property Owner Information)
iI
ature
P��Type Name
`6 L. ►3 k.E 0 r t vL
M in Address zw71
et N
City§tateal �p # r�
Telephone Number
/-31, I<:�
Date
(Revised 611812012)