Mistrot, Jacques

CAMA / 'DREDGE & FILL No. 73372 A B CC / D
GENERAL PERMIT Previous permit #
New Moidification ._Complete Reissue -_ Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality fWo
and the Coastal Resources Commission in an are f environmental concern pursuant to I SA NCAC
E Rules attached
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Applicant Name
Project Location: County -/
Address C, Street Address/ State Road/ Lot #(s)
City— e-7 e-t State, k C zi P� J66
Phone#�7 E-Mail Subdivision
Authorized Agent City Awi ZIP 71-1
;;Fffs E PTS Phone #
Affected D CW DEW El PTA River Basin
L-1 OEA [_1 HHF D 1H 0 UBA D N/A nat /man /unkn)
AEC(s): _Z PWS: Adj. Wtr. Body —
Closest Maj. Wtr. Body e, Gs
ORW: yes / no PNA yes / no
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Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
1p'plicatio'n 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 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/ 1-888ARCOAST
252-946-6481
Fax: [phone]
Fax: [phone]
(Serves: Carteret, Craven, Onslow -
(Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet- and Pamlico
Tyrrell and Washington Counties)
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)
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

APPLICATION:
LOCALITY:
PERMIT ISSUED USING
STATIC LINE EXCEPTION?
YES NO
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SL1FWEY F64
In�o� DES Misr�or

7322 �csn���
RECEIVED
DEC 2 7 20118
DCM-MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ,V - C�-- 7 s� < /� ��%�%%�G Is
ame of Property Owner)
property located at 7�Z SC�'C�/l,�%� �c
(Address Lot,? �/� Mock R d tc.
L
on(iG�S , in N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location!
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)
DEC 2 i 2018
0CM.MH p C17-y
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Telephone Num er/emai address
Date
t Property Ow or Informati
Print or Type Name
Mng Address �
r� �
City/State2ip
Telephone Number/email a dress
Date *�
-<-'t F, & 7 1 ( � & /4 Aj' 4 1 (- I (Revised Aug. 2014)
*Valid for one calendar year after signature'

ADJACENT RIPARIAN PROPERTY OWNER ftTATEMENT
hereby certify that I own property adjacent to 's
„ _ r-, _ ame of Property Owner)
prc
and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
+/ 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)
ReOelvtiD
M Myn CITY
IVER 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. /(IIf, ^you wish to waive the setback, you must Initial the appropriate blank below.)
iJvv I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owne Info ation) (Adj t Prope Owner Information)
Si re G Sign e B 4,4e1
Print or y a e Print or Ty e N me
D `73 �f Jou1,0- zr
Mall; ddr ,s Mading Address
T Ce n%G 8�9�
C; /Z; Citylstatel4ip
/' ' w� e: ��� • ��
Telephone Numperlemaff address Telephone Number) em rI address
1A. it • I?
Date Date*
A0/ 07 / ,�- (4? 6'1414) 6 C641 (Revised Aug. 2014)
"Valid for one calendar year after signature*

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