Buglovsky, Ed

gFE'
GE & FILL
RAL PERMIT
Modification Complete Reissue Partial Reissue
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
Applicant Name
Address
City-- State— ZIP
Phone # ( —) E-Mail _
Authorized Agent '
Affected ❑ CW NEW � PTA [I ES [IPTS
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
AEC(s):
❑ PWS:
ui. - / .. DATA
No. 73383 A
Previous permit #
Date previous permit issued
Rules
B C D
Project Location: County
Street Address/ State Road/ Lot #(s) _
Subdivision
rite
Phone # ()
Adj. Wtr. Body
Closest Maj. Wtr. Body
ZIP
_ River Basin C
/(nat /man /unkn)
Type Project/ Activity
of
(Scale:
}
t►f
)
Pier (dock) length
I
--
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
1
Groin length _
i
number
Bulkhead/ Riprap length `r
j
1
avg distance offshore _
max distance offshore
Basin, channel
i
i
cubic yards
I
1
Boat ramp
Boathouse/ Boatlift �
i t 1
TE
-- - — - —
i
Beach Bulldozing
Other
Shoreline Length
SAV: not sure yes
t /
I .
i
Moratorium: n/a yes i no
Photos: yes j no
-
- -� -
I
Waiver Attached: yes no
A building permit may be required by:
See note on back regarding River Basin rules.
( Note Local Planning jurisdiction)
Notes/ Special Conditions
�i
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
Check #
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 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
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
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)
http://portal.ncdenr.org/web/cm/dcm-home
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)
Revised 7/06/17

Adjacent Riparian Property Owner's Statement
Adjacent Riparian Property Owner:
Section Number: CS Lot Number: c) 9
Name: C F_ d
Address: �,, /09)
Telephone Number:
E-mail Address:
I hereby certify that I own the property adjacent to:
Section Number: O S
Owners Name:
Lot Number: D Yl 5-
Address: 10 1 S CB'1 UU 0�E_ 2 Cr
Telephone Number: v�5 - ;� R-k - U I
E-mail Address: S' h �C) �C��Gt ,��►�1� n�J
The individual applying for this permit has described to me the scope of work as shown on the attached copy of the
"Description and Drawing of Proposed Work" form and have no objections to the proposed work. I understand that
docks, pilings, tie poles or any other marine structure must be set back a minimum of fifteen feet (15'-0") from my
riparian line unless waived by me.
I do not wish to waive the setback requirement.
I do wish to waive the setback requirement.
Adjacent Riparian Property Owner:
Signatore�
Print Name 0E 01-- V LL U ka. A
Date

Adjacent Riparian Property Owner's Statement
Adiacent Riparian Property Owner 0
Section Number U S Lot Number:>I
Name:
CCk
Address: i'.-, 10
Telephone Number: =
E-mail Address:
1 hereby certify that I own the property adjacent to:
Section Number. O S ___ Lot Number:
r
Owners Name:
_ - - --
Address: S + 1 �_L1_%� -_ Lr_ -
Telephone Number:_SC
E-mail Address:
The individual applying for this permit has described to me the scope of work as shown on the attached copy of the
"Description and Drawing of Proposed Work" form and have no objections to the proposed work. 1 understand that
docks, pilings, tie poles or any other marine structure must be set back a minimum of fifteen feet (15'-0") from my
riparian line unless waived by me.
I do not wish to waive the setback requirement.
V l do wish to waive the setback requirement.
Adjacent Riparian Property Owner:
Signature
Print Name
Date