Simmons, Douglas

CAMA / DREDGE & FILL '°
A B C D
GENERAL PERMIT Previous permit#
Nevv Modification L- I 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
J Rules attached.
Applicant Name ✓�� � .� � a _ Project Location: County
s,
Address f`�'' ��� �Street Address/ State Road/ Lot #(s)
F
r
-state ZIP ` 5
City_ -
Phone # () i E-Mail
Authorized Agent
CW �M -} ] PTA El ES [IPTS
Affected - OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
AEC(s):
PWS:
ORW: yes / no PNA yes / no
Subdivision
City ZIP
Phone # ( ) River Basin�'f'
Adj. Wtr. Body ` nat man unkn
Closest Maj. Wtr. Body 6',' t ✓
11
Type of Project/ Activity
(Scale:
)
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
number
i
Bulkhead/ Riprap length—
I
avg distance offshore
max distance offshore
',
1.
`
�
Basin, channel
—I—
y
cubic yards_
4—
Boat ramp
Boathouse/ Boatlift—
,
j—
Beach Bulldozing
Other
W'
Shoreline Length
SAV: not sure yes no
-
.-_
Moratorium: n/a yes no
Photos: y.,no
Waiver Attached: yes no
Ea —
A building permit may be required by:
❑ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction)
Notes/ Special Conditions
<`"% 49
Agent or Applicant Print d Name
Sign Please read compliance statement on bacTc of permit_
ication Fee(s) Check #
Permit Officer's Printed Name ­—'"­-"—
SignaSigna ur
r 4Eration
Issuing Date '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 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

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
A n w I (Name of Property Owner)
property located at J ffTA//C 4V
(Addre
on
(Waterbody)
;; Lot, Block, Road, etc.)
in Ct-6 I-- s*-C�& e , N.C.
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
t
ti 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 description below or attach a site drawing)
RFdtWFn
C-� 0 4 201
OCT 8 4 l Hp cJT
VICAw s
WAIVER SECTION
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.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
perty Owner Infor a 'on) (Adjacent Property Owner Information)
ature_ Signature
Print or ype ame
M iling Add're
City/StatelZip
�4Lo 1 �s
Telephone Number
Date
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number > �/
Date
(Revised 611812012)