Sherrill, Lynn

it/
CAMA / !, DREDGE & FILL
A B C D
GENERAL PERMIT
Previous permit #
DNeW DModification ❑Complete Reissue
❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
environmental concern pursuant to 15A NCAC
and the Coastal Resources Commission in an area of
Rules attached.
;,•�.
Project Location: County____----------
Applicant Name �- �.�:
N+ Ill. # '
Street Address/ State Road/ Lot #(s)City ti _
Address
State_ . ZIP
Phone # ('�- E-Mail
_ Subdivis4on —
-,
Authorized Agent
f
City ZIP f / r , .E _ , ,, {
j
❑ CW ❑ EW ❑ PTA Ej ES ❑ PTS
Phone # () Rivgr Basin
Affected J OEA ❑ HHF _ IH ❑ UBA ❑ N/A
I'-,"
Adj. Wtr. Body � . ✓' - unk�
AEC(s):
❑ PWS:
Closest Maj. Wtr. Body �—
ARW vPc / no PNA ves / no
Agent or Applicant Printed Name
Permit Officer's Printed Name
Signature ** Please read compliance statement on back of permit
Application Fee(s) Check #
Signature -f
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: [phone]
(Serves: Carteret, Craven, Onslow -
North of New River Inlet- and Pamlico
Counties)
Elizabeth City District
1367 U.S. 17 South
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://www.nccoastaimanagement.net/
Revised 08/27/ 14

I
N.C. DMSION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Name of Property Owner Applying for Permit:
Nailing
Addresss:'
u64 0 4 -
I certify that I have authorized (agent) 0 5to act on my
behalf, for the purpose of app"gg,ffar and obtaining all
CAMA Permits necessary to
install or construct (activity) OPe P &tea
at (my property located at) 1 7 7 ��' �✓ �"r[ G' �l „*' ''OC " /l%G
This certification is valid thra (date) fA d
Prope ner Signature Date

CENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby Certify that I own property adjacent to Ck✓/✓� p yp� 1f
perty Owner) s
Property located at Z!�i % j �,'„ slam of P
r ' A ress
(ockRo&d
on K/CS�%y%►�1% in A-r S
(Waterbody) ---- -- " orC )
(CityfTown and/or n-
The applicant has described to me, as shown below, the development proposed at the above
✓
locatiop
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION ANDiOR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
/-
�tN
jade
WAIVER SECTION,
1 understand that a pier, dock, mooring pilings, boat ramp, ter, boathouse, lift, or groin
miud 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 Intttal the appropriate blank below-)
✓ ✓ I do wish to waive the 1 V setback requirement.
I do not wish to waive the 15' setback requirement,
(Property Owner Info7/56>_o ( I tfJOpY Owner Information)
/`C�7 /uY b^A-K—r FoyQ/e--
G 4�tB f7 / Z7111due—
�— 25 2ts Date'
'Valid for one calendar year after (Revised Aug. 2014)
Y signature'

• Mar 26 18 11:44a BRENDA GODFREY 336-769-9490 p.2
en cerF IT RIPARIAN PRO�KnI ./ It /I�TaT�' t
1 hctr+.try t!I♦•fy ttrst i Own prtperty gd/eoent tO �� 8i P 1-Pi 4
property I� 5
of }pert
xAead LCJ ' l __�.�
on Gl y�f. _..%i _ .1n .csig c fJ E
(vuatertrudy) (CQyrToem antNOr ntYl
The wp%mnt has 09eortneo m me. as stwvn, below, the davelophwrtt pr000sw at the above
IocaGon, W tm proposal.
I fitwe nc ottjectlon
1 ill ohjecwm to tMl prapnsal.
— — OUSCTaPTFON ANOIOR ORAYNNG Of PROPOSED WM OPWW
(/ndivlduai propering de►aiioprhent nuLV fill In descripUp" bsfow or 80ach A sItn drswI
wjeI k
adG op•e� ►"5
ftiyER srcTttJal
I underst id that a pier, dol rnemin8 pflirl bo8t ramp, bremkwater, boethou , lift. or gram
r el be set beck a rtttrtitnum distal of 957 trgtn ray Dreg at riparian access unless waited by
T.e. pi you wish to wove the setback, yov mast irNtl/l Vw eppkotrate bterk betow. )
Dare
C7 wt h tf` v wo thA 151setbarh wUirefrcenl.
on not wish to waive the 1 S satblck
'Valid for one cmel vmw SAer m9^ .
jace"t property
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