PKS Properties LLC

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CAMA / DREDGE & FILL No 71614 A
GENERAL RAL PERMIT Previous permit #
CNew 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
7 Rules attached.
Applicant Name
___ _____ __ __ __
Project Location: County
Address
Street Address/ State Road/ Lot #(s)
City
State _ ZIP
_
Phone # (_ )
_ E-Mail
Subdivision
Authorized Agent
City ZIP_
❑ CW
❑ EW -_ PTA ES E PTS
Phone # ( _) River Basin
Affected
❑ OEA
❑ HHF ❑ IH ❑ UBA ❑ N/A
Adj. Wtr. Bod
❑ PWS:
Closest Maj. Wtr. Body -- -
ORW: yes / no
PNA yes / no
Type of Project/ Activity
Pier (dock) lei
Fixed Platforn
Floating Platfc
Finger pier(s)_
Groin length
number
Bulkhead/ Rip
avg dista
max dist
Basin, channe
cubic ya
Boat ramp
Boathouse/ B
Beach Bulldo:
Other
Shoreline Ler
SAV: r
Moratorium:
Photos:
Waiver Attac q ,
A building permit may be required by:
( Note Local Planning Jurisdiction) t
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit"
Application Fee(s) Check #
(Scale:
man /unkn)
E7 See note on back regarding River Basin rules.
Permit Officer's Printed Nam?'
Signature
3,r x;
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, certifythat 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/ 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 FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit k--� Fo
Mailing Address: AL- .
Phone Number: 3S33
Email Address: �% V -e (2®) . cull
I certify that i have authorized '/ i /�V� LLCvj
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: 04S
w
at my property located at
in �'— CPunty.
l furthermore certify th t I am authorized to grant, and do in fact grant permission to
Division of Coastal Ma agement staff, the Local Permit Officer and their agents to enter
on the aforemention lands in connection with evaluating infonnation related to this
Permit application. ,!
Property fo ation:
R Signature
" F nt or TVDe Name
M 141-
Title
iU_l
Date
This certirfication is valid through

ADJACENT RIPARIAN PROPERTY oWNM STATEMENT
I hereby certify that 1 own property adjacent to
property located at �-i-��;. (Name of ProperW )
on
(Address, UA, fit, Itoijl, etr.)
in
Mltvfrown andler County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above
location_
v, I have no objection to this proposal.
I have objections to this proposal -
DESCRIPTION ANDVOR DRAVING OF PROPOSED DEVELOPMEMT
(Individual proposing deaeloprMmt must fill in descdiWi6n beowz-, or arch a site d'raaviing)
45; � h e y�-WG'l
I 7 03 4E U1^r
2
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lifr, or groin
must be set back a minimum distance of 15' from my area of riparian access unless waived by
mef y u 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.
Information)
R " t vp�-+v
Telep 0,!%P0V/email address
iM
Walid for one calendar year after signature}
1 T.-
(%llti
7 t'L � �' �(L�(7
C(
M81f%1Add` tI1
Ti
Date* " j RECE 11F
(Revised Aug.fa
DCM_MHD CITY

Valid for one calendar year after signature's
ADJACENT RIPARIAN PROPERTY owNER STATEMERtT
I hereby certify that I own prqxwty adjacent to p
Property located at (vnW of Owner)
on
(Aridness, Lot, Bt RoaRoad, etc.)
, in
(City/Town and/or Countty)
N.C.
The a
locatio ppcant has described to me, as shown below, the development proposed at the above
`` . i have no objection to this proposal.
i have objections to this proposal.
DESCRIPTIONAND/OR DRAMMG OF PROPOSE ®EVELOPI�EMT
(MdMdua/ ProPosiagg dev%tamnt must flit car
plc®aa below or attacia a site o'aawea��)
B�rn,r,n Li
T b0 4.� \ z
IWAIVER SECTION
I understand that a pier, dock, mooring
pilings, boat ramp, breakwater, boathouse, lilt, or groin
rnust,be set back a minimum distance of W from my area of riparian access unless waived by
men' y u wish to waive the setback, you must initial the ap
propriate blank below.)
I do wish to waive the 1& setback requirement.
do rOt wish to waive the 15' setback
Information)
Owner Information)
7fI C
Pri. TZ !'t VIIIIND i I
opber/email address
7*'
/ mail address -�
0 U�
N
(Revised Aug 2014
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