Dixon, Debbie

-CAMA.? 1-G43EDGE & FILL No. 74423 A B C D
GENERAL PERMIT Previous permit #
-_ New _-Modification Complete Reissue Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
�)C ' I
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC /.
❑ Rules attached.
Applicant Name
-' i Project Location: County_
- � _ - --
Address / - Street Address/ State Road/ Lot #(s)
State_ ZIP _
Phone # ( -� i ` �'-1 -t-Mail —
Authorized Agent
CW
EW
❑ PTA ❑ ES ❑ PTS
Affected
❑ OEA
_
_ HHF
ElIH ElUBA ❑ N/A
AEC(s):
❑ PWS:
ORW:
ves / no
PNA
yes / no
Type of Project/ Activity
Pier (dock) lei
Fixed Platforn
Floating Platfc
Finger pier(s)_
Groin length
number
Bulkhead/ Rip
avg dist2
max disc
Basin, channe
cubic ya
Boat ramp
Boathouse/ B
Beach Bulldo.
Other_ _
Shoreline Lei
SAV: r
Moratorium:
Photos:
Waiver Attac..__.
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
'� k x ►^-
Signature ** Please read compliance statement on back of permit*
Application Fee(s) Check #
Subdivision
City ,P : r�f ZIP
Phone # () _ River Basin
Adj. Wtr. Body.i _ (nat /man /unkn)
Closest Maj. Wtr. Body r
(Scale: )
C See note on back regarding River Basin rules.
Permit Officer's Printed Name
Signature
Issuing Dat Expiration bate

f J
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/ 1-888ARCOAST 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)
http://portal.ncdenr.org/web/cm/dcm-home
(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

Hurricane Florence and TS Michael
Replacement/Repair Request Form
Date of Request: I
Property Owner Name:
Address of Property:
Telephone Number:
Type of Work:
' C\ @iY~
NOTE:
• The Emergency CAMA General Permit 2500 is for repairs and replacement of water -
dependent structures damaged because of Hurricane Florence and/or TS Michael. The
replacement, reconstruction and maintenance excavation activities shall conform to
current standards and rules. All work under the Emergency CAMA GP 2500 must be
made in the same footprint of the previous structure with no additions, expansions, or
enlargements.
If any portion of a structure being replaced is within the 15' setback of the riparian line or
access area, signatures of the adjacent riparian property owner(s) must be obtained
acknowledging the notification and waiver of the setback on the forms provided by
DCM.
• Any maintenance excavation or dredging requires signatures of the adjacent riparian
property owner(s) on the notification forms provided by DCM.
Signature:
ftsof'o
MP No G��Y
®GM V

��;q—)263-eel
ADJACENT RIPARIAN PROPERTY OWNT T MENT
i hereby certify that I own property adjacent to (/�b) 'e' j o
S
property located at 1,26- y, (Na a of Property Owner)
dd ess, lot, > f' Road,qtc.}
on df Q( S n w� d N C
(ovate dy) (City/Town and/or County `)
The applicant has described to me as shown below, the development proposea at the above
location.
V_`_ I have no objection to this proposa<
! have objections to this proposal
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(fndlvr'dual Prapo>llilitrtg d"10PIMIllint must fill in descrfpt n Wow or attach s $ite drawing)
R�f 6 ►Y pi
J
Ja CIL-
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 f lus�it�i the appropriate blank below.)
I do wish to waive the 15' setback requirement
I do not wish to waive the 15setback requirement
(Property Owner tnfoltrtation) (Adjac nt Pro
, Pe Owner Information)
t `� K a
t� \ tit t7ppl3/t��,, '
! Pi )�Dy� k' !1. trrj'1 1) l(irr' r 5 S rrny Name Pnrlt or Tyge Name
Oayino d� 1� C LOG f }uo S -TT
Mailing Address
i email address
'Vali(J for one calendar year after signature'
cdy.'State'lz p
Tefepnone Number / emai1 address
F7ev+sed Aug. 2014)

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