73698A_Kubick, Frank P & Holly_20190815

CAMA / DREDGE & FILL
GENERAL PERMIT
XNew ❑Modification [-'Complete Reissue El Partial Reissue
No. 73698
UA B C D
Previous permit #
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 I SA NCAC 70, 1100
CK] Rules attached.
Applicant Name Fta " b1Ck. Project Location: County�c) wa h
Address H, 11 L- , • Street Address/ State Road/ Lot #(s)
City �ci k--t' TOE tateC ZIP � 7% j2 ; :x _Q i,r��t
Phone #C' r ) 32 `428(3 E-Mail {. �;ub Subdivision W'-i l +b2rY�,
Authorized Agent -aA i ck City C_ c) t n (] ZIP ;L 7g 3 .x
Affected ❑ CW [4 EW KI PTA YES I$PTS
AEC(s): ° OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes no PNA yes /'no'
Phone # ( ) River Basin r Ck'N�Q.A«
Adj. Wtr. Body_ �11 kC-/1rct, if CJ (Fat Jm�nkn)
Closest Mal. Wtr. Body �uykct < If SC- d
Type of Project/ Activity
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Agent
Agent or Applicant Printed Name
i� .ram
Signature Please read compliance statement on back of permit"
Application Fee(s) Check #
PermitOfficg ' P inte Name
Signature
�//5 /1 (I
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 (9 10-796-72 15) 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

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: F,,c,, h I - A i 61 4 6, L k Permit #:
Date: r�% l (5 / 1
`73(oq8 a
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
Dredge [IFill KI Both ❑ Other El�j
ccosirl
�'000''k4
G'-t�tO'+
Dredge ❑ Fill ❑ Both f] Other ❑
a(XJS
SF
Dredge ❑ Fill ❑ Both ® Other ❑©��
(� ��
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
252-808-2808 :: 1.888-4RCOAST :: www.nccoastaImanagement.net revised: 02/03/10

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: r�/ Nk P
Mailing Address:
Phone Number:
Email Address:
Z -?—
I certify that I have authorized .Joe -Ri dd <C1< ,
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: V3U-1k—e 4f d
at my property located at z Z Z AK w
in Cka.4--4 h County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature
P k IA- b I
Print or Type Name
Title
:I�/
Date
This certification is valid through / /

ADJACENT RIPARIAN PROPERTY OWNER S /T/ATEMENT
I hereby certify that I own property adjacent to rrQ h k P J&w I C-A- s
.A I , 1, ,(Name of Property Owner)
property located at Z Z If(
(Address Lo , Blo(;k, Road, etc.)
on 411 errs c.-1 e—So t4 and , in C4,o lv Y( C h04.4e. Co , 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)
%6— L K % &`,-4
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.
(Prope Owner
Information) (Adjacent Property Owner Information)
Signature JO
Signature
Print or Type Name Print or Type Name
Mailinq Add ess Mailin Address
City/State/Zip Z City/State2ip
?--G Z Co3 -f!o/S��>C>933 s�y//aux�Sa���cc�l. i
Telephone Number/email address Telephone Number/email address
yc • z4L • zd� 9 ,�
Date Date* �—
�. kc-k Pao
(Revised Aug. 2014)
`Valid for one calendar year after signature'

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to i" r''a,-.,-k P et& b t c�-- 's
I L (Name of Property Owner)
property located at (r' ZZ a
17
�p�/I (Add ess, Lot, Block, Road, etc.
on (aL the
al^I�F LSD t:� , in�C-f'>?'3'! �Zlul'#11�, N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locati�p I on.
1 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)
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.)
WJI do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Prope Owner Information) (Adjac nt P op; Owner formation)
Signature S 16W a t u
Print�or'Type ame / Print Type M71e& f
Mailin Address Ma ddr ssIf
�-f; Ai e z 7 �13 Z. �c� A Z 792 Z_
City/StatelZip T Ci e2i
Telephone Number / email address Telephone,/ / mbe / ail address
Date D*� //
b t L�
Dale* Q ,v+-c�Si • C 9 �J
t46 (Revised Aug. 2014)
*Valid for one calendar year after signature*

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