Haystacks HOA

7JCAMA / DREDGE & FILL �`NO. 73133 A
GENERAL PERMIT Previous permit #
1N ^M 4iAi ti^n ❑Complete Reissue '..L]Partial Reissue Date previous permit issued
ew — o
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.
A licant Name Project Location: County_
PP
Address f /'
City State ZIP
Phone # ( _ EAail
Authorized Agent
Affected ElCW ElEW ❑ PTA 4j ES ElPTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
ORW: yes / no PNA yes / no
Type of Project/ Activity
Pier (dock) length
--,
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length l
number %
Bulkhead/ Ripraplength'
avg distance offshore
max distance offshore
Basin, channel
cubic yards .'
Boat ramp
Boathouse/ Boatliff
Beach
Other
Street Address/ State Road/ Lot #(s)
B C D
Subdivision i —
City ZIP Z�
Phone # ( } ' ,fiver Basin
Adj. Wtr. Body _� (nat]man /unkn)
Closest Maj. Wtr. Body —
Shoreline LengthI I
SAV: not sure yes no .- — +
Moratorium: n/a yes no t
Photos: yes no
4
Waiver Attached: yes no
A building permit may be required by: ' r
( 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 #
(Scale:
❑ See note on back regarding River Basin rules.
Permit Officer's Printe a�y{e
Signature
Issuing Date Expirationf 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/ 1-888-411COAST
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

..ft
Hurricane Florence Repair Request Form
Name of Property Owner: f�%} %� Date:
Address of Property: ,� C� �%��' C u 13 fZ -ID
Mailing Address (If different than above):
Telephone Number. �� ;> `� /' 7
Repairs due to hurricane Florence will be made in the existing footprint of the previous permitted structure.
Signature:
RECEIVED
OCT 17 2018
***Please note that if the structure is within the 15' setback of the riparian line an9)QM7MliW#fu must
have the adjacent riparian property owner notification/waiver form signed.