Dempsey, Don

❑CAMA / ❑ DREDGE & FILL No 71367 A
GENERAL PERMIT Previous permit #
Fit INew ❑Modification ❑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 I SA NCAC
[:I Rules attached.
Applicant Name `/� Project Location: County
Address p Street Address/ State Road/ Lot #(s)
City State j' ZIP
Phone # ( ) E-Mail Subdivision
Authorized Agent City ZIP
[ICW ElEW L,PTA El ES ❑ PTS Phone # ( ) River Basin
Affected ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
AEC(s): El PWS: Adj. Wtr. Body ___(nat /man /unkn)
ORW: yes / no PNA yes / no Closest Maj. Wtr. Body --
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
r"
Shoreline Length
SAV: not sure yes of
Moratorium: n/a yes
Photos: yes no
Waiver Attached: es no
1 _ _
A building permit may be required by:
( Note Local Planning jurisdiction) f 1 _
Notes/ Special Conditions J '
(Agent or Applicant Prin
. frte Name
ti= _ lrf tr`
Permit Officer's
(Scale:
B 'C D
❑ See note on back regarding River Basin rules.
v
Signature ** Please read compliance statement on bacl,of permit.
Application Fee(s) Check #
Signature
Issuing Date
Expiration bate

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 Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 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

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit:
Mailing address:]
Telephone Number: -? ,6- --
I certify that I have authorized i:::- (agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of T —/ e4i4
at my property located at'�'
This certification is valid through —tO-1 Cl (date).
(Property Owner Information)
Signa ure
Print or Type Name
Title, co. owner or trustee for property
Date
g - -f2C7 - 9�a/
Telephone Number
Email Address

SENDER: COMPLETE SECTION COMPLETE . Q.
SECTIONON DELIVERY
■ Complete items `I, 2, and 3. A. ignature
■ Print your name and address on the reverse
so that we can return the card to you. Agent
® Attach this card to the back of the mail lece, (� y ( n to e _ lessee
f eceived b
or on the front if space permits.
p ) C. Date of Delivery
1. Article Adtlressed to: D. is elive add ss d' t e
If YES, enter delivery addroatie
23 -&\% m
I 0 �I< • p4�
h
3. Service Type ❑ Priority Mail Express®
I! ❑Adult Signature ❑ Registered Mai1TM
❑ Adult Signature Restricted Delivery Ml Registered Mail Restricted
9590 9402 2553 6306 4721 68 0 Certified
Mai Restricted Delivery ❑ Retu Receipt for
2. Artcle "• -� - r`_ —. __ - ❑ Collect on Delivery Merchandise
livery Restricted Delivery ❑ Signature ConfirmationT"^
7 017 1450 0001 1777 0336 U Signature Confirmation
Restricted Delivery Restricted Delivery
over$500)
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Properly Owner.
Address of Property: fo°i No�� ,r lnc� 90.
(Lot or Street #, Street or Road, C4 & Cou
Agent's Name #: C.� - Zr, _ Mailing Address: V �J_ 01 1J.Q ,(A l _
Agent's phone VA 5 a - a,40) -
q71
I hereby certify that I own property adjacent to the above referenced property. The individual
app'rying for this permit has described to me as shown on the attached drawing_the development
they are / posing. A description or draw[no wish dimensions �+�,Q+ wg iov��ad with this tear.
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 Aignsgement
(DCAQ In writing within 10 slays of receipt of this notice. Contact Inibrmation for DCM offices is
available at',:/hJur.orbycallingl-888.4RCOAST No twimnse is ennAiri armwi 4he ��r.e ®w .._ :_�aa__ ,i --- --
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
y04 wish to waive the setback, you mug Initial the appropriate blank below.)
'L I do wish to waive the 15' setback requirement.
I do not wish to waive the 151 setback requirement.
-Property Owner Information)
tLp .- J-Q'
��t�8 �� 5 � y r
6�A�
Jh
'Print or 7ypW Name
q-OA
Meiling Addre
clty&taftop
334- ya0-- 9gol
Telephone Number/Email Address
Dare
y �- 18 -�l y
(R'paftn PmPOrty O
wner Information)
S4gncrture �-- , j
P r Type Name
Adeaili»g Address ----� —.—�
C /5teteop
Telephone Number/EmeHAddress
f Z l !
Date
(Revised Aug. 2014)

DON DEMPSEY
674 DAWSON CREEK ROAD
ARAPAHOE, NC
DESCRIPTION
We propose to install a new boat lift on four (4) new pilings.
We propose to install two (2) additional pilings.

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