Kassay, Charles

N
uCAMA / 'E DREDGE & FILL No 71364 A B D
GENERAL PERMIT Previous permit #
❑New EModification ❑Complete Reissue ElPartial 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 j •.,_ Project Location: County
Address f
. � i% Street Address/ State Road/ Lot #(s)T o
City 'f State /- Zlpc F"
Phone # ( ) E-Mail Subdivision
Authorized Agent # City ZIP
❑ CW ❑ EW ❑ PTA ❑ ES 0 PTS Phone # ( ) -River Basin
Affected ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A E 1 , ,�,^, �..
AEC(s): { J�: T +f
Adj. Wtr. Body (n a unkn
❑ PWS:
Closest Maj. Wtr. Body
ORW: yes / no PNA yes / no
-- -
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
Application Fee(s) Check #
�w
Permit Officer's Printed ,Name .
Signature
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 I) 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/ 1-888-41RCOAST 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

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/ ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
r
^ereby certify that I own property adjacent to L4,JAAf -UE V-Jke7" Ar 's
(Name of Property Owner)
property located at 5CrUZ C ! t`-(� LL> I' i7 V—1y G
(Address, Lot, Block, Road, etc.)
on l�iCl,�.� lv`��- in CRA\tC:W f "ram N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc
I have no objection to this proposal.
I have objections to this proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must till in description below or attach a site drawing)
j (c0' x 3 t It-'J INAvy tlt.�rt A►i
J2-ociL op-A1>S , (12L-vtc tAAP-1;0,J
Sx'g VD? ,TS j P11.1; 2x'8 WoB19 e AP.
W1r-Cal0AC)'- 0rJ LEf-r -�,IOC ',-ftt-/r-► i"0
92vL,V�-rtCP<0 ot-3
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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.)
N tTf�v I do wish to waive the 15' setback requirement.
--'7 I do not wish to waive the 15' setback requirement.
Owner Information)
nip -A�w-IiiM AeiEriT"
.Signature
Pr t or Type Name
V107— ORIVO
Mailing Addr, ,s
/I : 5-t. r-j t tJG 2 S1Zr Z-
city/State ip
( U51)524i -'73ZZ
Telephone Number/email address
y-Z�-Zoto
Date
`Valid for one calendar year after signature,
Owner information) -1-i C-+t k�
a J 01kr.l (-IV PA tTl,i
Print or Type Name
Mailing Add ^s
fir✓ '1 S-ZJ v
city/ tate�ip
Telephone Number/email address
Date
(Revised Aug. 2014)
Scanned by CamScanner

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to G�(.1 I✓`� S
(Name of Property Owner)
property located at\1::1
(Address, Lot, Block, Road, etc.)
on , in Gs-p'-0l�TS G1 NTN.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location. h aV2
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)
Li ; 2 x 8 W cs IiAdP. rr
�f 4f� i i 1 CZ% co SCE \ i to � OU
UJ i tJL F7-AC V - t7 f 3 liJFi� �✓ 0 i TLC i✓kl S-i l is C`� QdSb�i
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WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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.)
1 Q ITl -- i I do wish to waive the 15' setback requirement. C- �G1
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjace roperty Ow formationy Lt'FT'
U>�` i th' f�.l Z%C +' GCS_
Signature Si a e
r'A V - c L-1 t Y- F cal '17
Print or Type Name Print or T pe Name
Mail/ n Ad ress Mailin Address
City/State ip City/State/Zip
Telephone Number/email address Telephone N ber/email address
Date y�j bate*
(Revise Aug. 2014)
`Valid for one calendar year after signature`

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