Henderson, William

❑1CAMA / ❑ DREDGE & FILL ' - NO. 73255 A B C
GENERAL PERMIT Previous permit #
New ❑Modification ❑Complete Reissew F-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 t, /
Project Location: County
Address ," '' t
Street Address/ State Road/ Lot #(s)
City _
State ZIP
Phone # ( ) ` ' " `
E-Mail
Subdivision
Authorized Agent
City ZIP
❑ CW ❑ EW
0 PTA ES ❑ PTS
Phone # ( ) i ' River Basin
Affected
J, OEA ❑ HHF
AEC(s):
❑ IH ElUBA El N/A
Adj. Wtr. Body �� ' � (nat /man /unkn)
PWS:
Closest Maj. Wtr. Body =— -- - --
ORW: yes / no PNA
yes / no
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s) —�
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore -�
Basin, channel -
cubic yards --
Boat ramp -
Boathouse/ Boatlift
Beach Bulldozing
Other /
Shoreline Length
SAV: not sure yes no
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
a A,_
Agent or Applicant Printed Name
Signature' Please read compliance statement on back of permit
(Scale:_----- )
❑ See note on back regarding River Basin rules.
Permit Officer's Printed Name
Signature
1 1
i
Expiration Dat
Application Fee(s) Check # Issuing 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:
r-
,_! 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/ 1-888ARCOAST 252-946-6481
Fax: [phone] 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)
(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

RECEIVED
Hurricane Florence Repair Request Form OCT 0 9 2018
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DCM-MHD CITY
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Name of Property Owner: i��J /�pv /� l3 tX's hr-- Date:
Address of Property: /.� (%UGC S/��ylG G ` G` e,
Mailing Address (If different than above):
Telephone Number: ;757Y ZVl z3d
Repairs due to hurricane Florence will be made in 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 dredging you must
have the adjacent riparian property owner notification/waiver form signed.

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