Chadwick and Associates

K CAMA /,e DREDGE & FILL NO. 73433 A B C D
GENERAL PERMIT Previous permit #
F- New --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 15A NCAC V
Rules attached.
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Applicant Name - V-Y"j F,r r /t,,� Project Location: County > �"
Address E ;' /' Street Address/ State Road/ Lot #(s)
City ( ,�' f States ZIP
Phone # ( » ) !'.'� ' { `"t-Mail Subdivision
Authorized Agent City zip
CW EW 0 PTA DES ❑ PTS Phone # ( ) River Basin
Affected OEA HHF C IH ❑ UBA ❑ N/A
AEC(s): Adj. Wtr. Body �%�✓ -�ti'"""?(nat /man_/unkn)
PWS:
ORW: yes / no PNA yes / no Closest Maj. Wtr. Body
Type of Project/ Activity
(Scale:
)
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
Shoreline Length
SAV: not sure yes no
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no
A building permit may be required
( Note Local Planning jurisdiction)
Notes/ Special Conditions
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See note
on
back
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regarding
River
Basin
rules.
Agent or A�plicant Printed Na
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Signature -* Please read compliance statement on back of permit
Application Fee(s) Check #

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 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

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PR ERTY OWNEROTIFICATIO /WAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City & County)
Agent's Name #: %o�--�
Agent's phone #:
Maili Addre s: ��� d✓ �� ©' "??.
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 pro ing. 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://www. nccoastaimanagement. netlweb/cm/staff-listing or by calling 1-888-4RCOAS T.
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 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 Owne rmation) (Rip iand Property Owner Information)
.Signat
Print or Type Name
Mailing Address
CWfStatelZip
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Telephone Number 7Email Address
Signature
Rebceca,D, \/\/"II "s
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number/Email Address
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Date
(Revised Aug. 2014)

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CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City & County)
Agent's Name #:
Agent's phone
Mailing Address: or
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://www.nccoastaimanagement.netlweb/cm/staff-listing orby 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.
<PJ�— I do not wish to waive the 15' setback requirement.
(Property wiie�io
Signature //�� __�
4�& 4:;;9 /'� c
Print or Type Name
Mailing Addres a
City/State/Zip
c;25'� - 7a1 i57 G-7 =moo
Telephone Number/Email Address
/; — (' /— /
Date
(Riparian Property Owner Information)
U.
gnature
Print or Type Name
1 �Lo 9c-Nz) 206.0
Mailing Address
/U -Cr
City/State/Zip'
Telephone Number/Email Address
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Dat
(Revised Aug. 2014)

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