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❑ CAMA / DREDGE & FILL No 71634 A B C D
r. GENERAL PERMIT Previous permit# --
❑New Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality - ./�f :. �-r .
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
[Rules attached i
Applicant Name Project Location: County
r
Address
City
State_ _ZIP r❑
Phone # (.—) _ E-Mail
Authorized Agent _
❑ CW �11 EW ❑ PTA
Affected
ElOEA E HHF ❑ IH
AEC(s):
❑ PWS:
ORW:
yes / no PNA yes / no
Type of Project/ Activity
Pier (dock) length '
Fixed Platform(s) K
Floating Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
ES ❑ PTS
❑ UBA ❑ N/A
cubic yards4t -
Boat ramp 4:
Boathouse/ Boatlift
Beach Bulldozing
Other^ !
r"
Shoreline Length _
SAV: not sure yes no
Moratorium: n/a yes no.
Photos: yes ;' no
Waiver Attached: yeno
A building permit may be required by: !'
( Note Local Planning jurisdiction)
Notes/ Special Conditions
r
Agent or Applicant Printed Name
Sig ure "Please read compliance statement on back of permit"
Application Fee(s) Check #
Street Address/ State Road/ Lot #(s) # 4A
Subdivision
City -
Phone # (_ )
Adj. Wtr. Body_
Closest Maj. Wtr. Body
ZIP
River Basin
fat /man /unkn)
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(Scale: / '✓" ,� )
See note on back regarding River Basin rules.
ed Name
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/ 1-888ARCOAST
Fax: 252-247-3330
(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:252-264-3723
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Washington District
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Fax: 252-948-0478
(Serves: Beaufort, Bertie, Hertford, Hyde,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext.
Wilmington, NC 28405-3845
910-796-7215
Fax:910-395-3964
(Serves: Brunswick, New Hanover,
Onslow - South of New River Inlet -
and Pender Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7106/ 17
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: JOH/VA41,-7"a a C�•.E-,�T
Address of Property: ��� -��� T� �� ��d�GArT A& Z�%6 �i4rst2-JL/7
(Lot or Street #, Street or Road, City & County) //��
Agent's Name #:1 7,4 Mailing Address: 2 D $;0e Z-e 4 ��'fL7�1#..e6 MC,
Agent's phone #: o? ,!fA
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing with dimensions must be provided with this letter.
4�w I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at http:llwww nccoastaimanagement net/weblcm/staff-ltsi i or by calling 1-888-4RCOAST.
No response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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.)
�� I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Pr Owner Information) (Riparian Property Owner Inform tion)
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Sig tune Signature
Print or Type Name Print or Type Name
2 b� .SPi_g sr
Mailing Address Mailing Address
z1*,J4*N c�'". NG Zfs"s� Akte-�Pol2- iA)C aS 175
City/State/Zip City/State/Zip
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Telephone Number/E Address a Telephone Number/Email Address
1� ho / 8
Date Date
(Revised Aug. 2014)
CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER/N'OTIFICATION/WAIVER FORM
Name of Property Owner: - J6.,wa %iZlif ✓ K 4�,,-t
Address of Property: a W %Egf Z74E I—X /VFAy/'s.r7 /uC 76 (,i�0-7-
(Lot or
Street #, Street or Road, City & County)
Agent's Name #:a (. ���- Mailing Address: Zal
Agent's phone #: 1-5" Z Z4 Ae4o.s-« AC
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at http.lhvww. nccoastalmanagement.net/web/cm/staff-listing or by calling 1-8884RCOAST.
No response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Infor atio
Signa a //JJ
JOHP
Print or Type Name
201 S�f'ue P
(Riparian Property Owner Inf rmation)
Signature
%WliLA,ak't C. 5)4AVFR—
Print or Type Name
H-)Iv r3jF'1.=C.w1
Mailing Address Mailing Address
City/State0p Z City/State2ip
Illy C"r,44.�� o�►p�7a�ja�. 3 3�— ��� � — 3� > _ , s�.�.� �� I�
Telephone Number/Email Addres Telephone Number/Email Address
-4
Date Date
(Revised Aug. 2014)