Horton, Neil

`MCAMA / DREDGE & FILL
-. GENERAL PERMIT
--New _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
—State ZIP
Phone # (_ ) _ E-Mail
Authorized Agent
Affected ❑ CW ❑ EW ❑ PTA -kES ❑ PTS
❑ OEA ElHHF [IIH ❑ UBA ElN/A
AEC(s):
❑ PWS:
ORW: yes / no PNA yes / no
Type of Project/ Activity
Pier (dock) length_
Fixed Platform(s)
Floating Platform(s) _
Finger pier(s)
Groin length
number
Bulkhead/ Riprap len€
avg distance offs
max distance ofi
Basin, channel
cuoic yarus -
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
Shoreline Length
SAV: not sure
Moratorium: n/a
Photos:
Waiver Attached:
A building permit may be required by: `
( Note Local Planning jurisdiction)
Notes/ Special Conditions
No. 73970 A
Previous permit #
Date previous permit issued
B C D
Rules attached.
Project Location: County - _-
Street Address/ State Road/ Lot #(s) ` ! / %
Subdivision
City r (. _ I ZIP
Phone # ( _) River Basin <_
Adj. Wtr. Body (nat /man unkn
Closest Maj. Wtr. Body
(Scale:
f
5/ See note on back regarding River Basin rules.
Agent or Applicant Printed Name
Sig ature Please read compliance statement on back of permit **
t 1(
Application Fee(s) 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 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)
(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 FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit: j 4
Mailing address:
Telephone Number:
L
(aje-I certify that I have authorized D6A`t, W'Kk�SEfL ^ (agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of
CC2-
at my property located at
t 1"-) WAs o -k� ►�. e� C� I?- o D j
20 �
This certification is valid through beC- (date).
(Property Owner Information)
Signature
�E((. 4OPTo N
Print or Type Name
'fop�r y
Title, co. owner or trustee for property
3 //5V/1
Date
Telephone Number
1�1P �/1Df--tOv\O 60VVLC3St f�
Email Address

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSIBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to NCI t RADA is
(Name of Property Owner)
property located at /36- �/%�� eo " 0
(Lot, Block, Road, etc.)
on Aft �W �l ['.Q� , in , N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location,
and, I have no objections to his proposal. I understand that a pier/mooring pilings/boatlift/boathouse
must be set back a minimum distance of fifteen feet (15') from my area of riparian access unless
waived by me.
I do not wish to waive the setback requirement.
I do wish to waive that setback requirement.
---------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
KIM '6 q Ak-U ".LU . k t 1 � ljJqS dafYQPd &C-:A�, KLA rr1 Cam.
--------------- ----- - --- ------------------------
Signature
Print or Type Name
2 5.1 5.,13 g�®/
Telephone Number
Date: 3 — !V- /5

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to K'el � POCLew1 's
(Name of Property Owner)
property located at—AyY /
(Lot, Block, Road, etc.)
on ",U' i �i.-�, i t)e /& On ' Z4Tr, . l Gy tl-11194r 4/A, N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location,
and, I have no objections to his proposal. I understand that a pier/mooring pilings/boatlift/boathouse
must be set back a minimum distance of fifteen feet (15') from my area of riparian access unless
waived by me.
I do not wish to waive the setback requirement.
• I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
1aAA 04 Akc 644 14 A kL
ktk, G� •� house.. HA W4,S d4VV\q J aLlrr n.3 'I WL,Cara.
--------------------------------------------------------------- ------------- ---------------- ---------------------
Signature
,OE44 d
Print or Type Name
Telephone Number
• Date: a-

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