74062_Herbert Worthington_20190814

0 7 CAMA/ L DREDGE & FILL D (v41OC7(4 No. 74062 A 'B C�
GENERAL PERMIT = Previous permit#
> - ', New ❑Modification ❑Complete Reissue pPartial Reissue 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 5A NCAC i/-/ • /2- c)
Rules attached.
Applicant Name /9/EX-5E1¢T /i✓or.-r-t-i, G,--->J Project Location: County c i F v.�le ((el .
Address 2 712 L... x �A. /4-^ %,.J , Street Address/State Road/Lot#(s) p17.-1 . 2 , '
City 7<<-E --h/1„,/r 4 L: State i ( ZIP Z. ".7 j' L:. __, .:: •f- .-a a a�.; a A.-i ,-.i l5 4/ •
Phone# ( - :. j/.y - 7/43 431 E-mail Subdivision 3,-* / LM L 5
Authorized Agent rreAiLl i1•-14) `./4 City </-iDcoLa i-.I,} , 1 ZIP 2 S' /-7
1 Cw 0 EW JPTA ❑ES ❑PTS Phone# ( )_- -__ River Basin TA: - A,N-7_i w
Affected -OEA HHF ❑IH CIUBA ❑N/A ' /
AEC(s): Adj.Wtr. Body ' ',-/-/"'' - & c:./1') el - (nat /man /unkn)
PWS:
ORW: yes / no . PNA yes / np� Closest Maj.Wtr. Body ��""''c'-' /v��
Type of Project/Activity _,�,./y r-Z u,-7 '� De GX , 'z!> > /8 /- /„,-3- ----c .,,,,--'1
(Scale: / = Z c7 )
Pier(dock)length f'X.- k '
LL I I I I
Fixed Platform(s) w 1r/D i I I
Floating Platform(s) i.—._.........._._ i
Finger pier(s) 1
Groin length . ,
•
number
Bulkhead/Riprap length • " i
• j
avg distance offshore yY1r-7„ tvrn_.e, e 2'.'� 2 � _
max distance offshore j /' / a ',.../ 14/QT- .! I
w I
Basin,channel I 1 I / I
I . - - ! �
9 1 1 i-
cubic yards —_ '___
Boat ramp I - iI
Boathouse/Boatlift — - I tis .— 2 - . .. I E�'5 4 `
I _
�..-._.__ - `tZ_
Beach Bulldozing - !
l ! t. _ 'b1
OtherT
11'111' 41 : tlljIr11 i::,
Y -
Shoreline Length- 3 S D I Pe-DP
A SAV: notsur yes no . � � .i_ — f I Ta , ,i/y ,✓ i
Moratorium: n/a yes . o_� _Irza, P ; //�p„il I j�IZNQ i I
Photos: yes I — t ' iii I i
Waiver Attached: yes no I
A building permit may be required by:;�/71--; DF 44-/a-74-7--) ,i- ,.s.! . ' ,See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions L.D T /5 /'-'+.41-7 AI`77- 7 ) L ri • G/"-L7 d t w-43/-4 - ry
2Di-17,-/ 1 /o,,.,/J6;/ti-F1.e 7.44-L.,4•lZ-o- Ar'Jc./c..4r-1 j 24?v-- j'c jav , .-
f'/_1—Z—r-DL/"1 i/'"'`h' "M L✓v1 A Z/v.. tr+' f ) • " D �12
,9/•/ ) AA f' GL�7 33p„ e' , i
Agent or Applicant Printed Name J Permit Officer's Printed Name
Signature Please rea compliance statement on back of permit Signatur
p/GI7/L M ZD0 Pe-7 / 4L414yti 2-D/9 ) / ,3rh 26/
Application Fee(s) Check# 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 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
reh Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 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 Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare, Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

Authorized Agent Consent Agreement
I 'a (I41 L Di aj�c1� , hereby authorize to act on
�$ . i 11,1 J (Authorized Agent)
my behalf in obtaining CAMA permits for the location listed below. This agency
authorization is limited to the specific activities described above.
Property Address:
324 (Y10054Z, LOGVICLUAO) V-0(
CAtOC,o N it n I.1h,\ MC
Property Owner's Mailing Address and Phone Number:
211 .2- Cox Four m
Q7tao.vv,1,111t lU
25 vi c$a 8
252 Al2 4q2
Property Owner's Signature: flUtAti Y;`t W
l
Authorized Agent Signature: �Q iZ/7,
Date: P- /3--
Form: Authorized Agent Agreement as developed by NCDCM revised 7/29/09

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to NQ-1' ,fit 1-&(, 1Y"Ct �i\Lal 'j LO-1(a-6yis
� (Name of Property Owner) �t
property located at S221 (i oo,. L euictulGt •�d, ( _I Li (.oto ni i A IL
(Address, ot, lock, Road, etc.), rr�`` �
,�LOCth�i i 1 iti �Q , in ' 1�GUl.0 ()l L LUf t
on C N.C.
(Waterbbdy) (City/TowrS and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
V 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)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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.)
U
Lev I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
kiMt"U\ID-Y( C ,,te C vi� w� u 1,
Siknat ure i nature
1-� 'Vi c�r�Itil I tc b i�eS+ Qi I. n iA dit,(b fait_
2rztior T e Na e Print or T pen
cuj
ailin Ad -d►i�n g��A d�dr sl a Ask NIL /165 �
tate/Z p
City/State/Zip
1 t zl o le ae) i5 1 In
Telephone Number T n lephoe mber
CcucA 3 Z Gt°I uc\ 3 u2 G I�
Date Date
(Revised 6/18/2012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
. f
I hereby certify that I own property adjacent to f f at f c) aCtli ,ta (,(JQ 11,4 . 's
(Nape of Property Owner)
property located at ,)24 C"i()CU La mil LIT/ IL-( . ('j,1 �� UlAi L C>
z (Address, Lot, Bck, Road etc.)
on C.LLVUCIA: IA.MA �3cu.-t . in 0,1,iLOT AA iYU NC ['el N.C.
(Watertdody) (City/Tow 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)
WAIVER SECTION
I understand that a pier, dock, mooring pilings. 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.)
\‘/C". I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
KG
X IA;L,, k, Ittal kYLLCM1AOL
Signature 1 Signature
_1 Q + 1��1 UY U.r1 : uSCUCLIA �,�'art c- iOt.
Printor
Type Name Pr Type Na e y
1Apilind Address Mailing Address
A
. n ,1)I J(€ LAIC �.1e ��t 4-QtAc1,►ikl_
Ciy/State,Zip City/State/Zip
/State/Zi
2 L�1 t4 Li tCt 76 ), (14 (4 a,,e o
Tel phone Number T phone umber
Date \ Date
(Revised 6/18/2012)

WASHINGTO
CITY OF
t I, tCOM P I a n C
" Certific
a k
_» _
ISSUED TO:
No.• % ' ' • o
;. DATE: •G 13 •
ONE: R ' �
SSUED
BY:
1111 THIS ERMIT MUST BE POSTED ON THE JO _ .

Glen Worthington has my permission to install and build a pier, dock, or
boathouse that would be in compliance with CAMA, City of Washington, or other
agency requirements for a permit in the Bay Lake canal system. Construction
would be done from his lot 12 section 3 or address 324 Goose Landing Road,
Chocowinity, NC 27817
4
Warren G. Whichard / V
Date Ayf/

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant J gE 1 6'12 ti1-221-‘)
Date: /L/ ret-LrG>u 5
General Permit#: 625
Describe below the HABITAT disturbances for the application. All values should match the name,and units of measurement
found in your Habitat code sheet.
TOTAL Sq. Ft. r FINAL Sq. Ft. TOTAL Feet FINAL Feet
(Applied for. (Anticipated final (Applied for. (Anticipated final
DISTURB TYPE Disturbance total disturbance. Disturbance disturbance.
Habitat Name Choose One includes any Excludes any total includes Excludes any •
anticipated restoration any anticipated restoration and/or
restoration or and/or temp restoration or temp impact
temp impacts) impact amount) temp impacts) amount)
0Pt-7N/ 2
Dredge❑ Fill❑ Both ❑ Other (0 S- 34i- (t,
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both 0 Other ❑
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other 0
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge 0 Fill❑ Both 0 Other 0
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge 0 Fill❑ Both ❑ Other ❑
• Dredge❑ Fill❑ Both ❑ Other ❑
•
1R' 4aam+r :_. 2+13.e.