75623A_Forbes, Robert & Sylvia_20191101

'CAMA / 1 DREDGE & FILL NO. 75623 6A B
�ENERAL 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
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC µyU
,$1 Rules attached.
Applicant Name Roly4r } µ. F,,i ,cs , 3r ; Syjura G. Foe beS
Address IIt. N. Nr,v-,
City Mc v r� 14.11 Stated ZIP �11-19 Si
Phone # (Jo ) 90-1 -IRS E-Mail
Authorized Agent
Affected El CW N(EW PTA ❑ ES ❑ PTS
AEC(s): E OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / r�ro PNA yes /,- o``>
Project Location: County
Street Address/ State Road/ Lot # (s)
Lit *e
Subdivision RI,
City M.- 1+,11 ZIP a-4951
Phone # ( ) River Basin
Adj. Wtr. Body C hu L..c , R , vt ng)/man /unkn)
Closest Maj. Wtr. Body A hK,,Y­ r j If lc
Type of Project/ Activity
(Scale:
Pier (4ockyltangth
Fixe,
Flom
Fingr
Groi
Bulk
Basir
Boat
Beac
Othr
Shor
SAV
Mon
Phoi
Wain
■■■■■■■■■■■■■■■■■■■■�■1■_■■e.�w■■■■■i
■■■
r pier(s)
i length
number
■■■■■■■■■■■■!1
i[�11�+�F�■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■��r�!�■■■■■■■■�■■■■■■■■■■■■■■■
avg distance offshore
max distance offshore
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■f■■■■■■■'
■■■■■■■■■■■■■■■■■■■■■■■i■i■■w9■�■■■■■■■
■■■■■■■■■■■■■�■��'�,■■�■■■■■■
�1��■■■■■■
cubic yards
■■i"�l�ll"'�©■■■■■■■
■■its■
■■■�ir��■■
1�■I■■■■■■■
ramp
■■■■■■■■■
■■■■■■■9I//■■■■■w�i■/�!
1�
1■■■■■
■■■■■■■■■■
nr■1�■■w�►ue■■■e■■��1►.i�i�
��■■■■■
���®iiii�iiiiiiiaiiiiiiiii��i
-1 Bulldozing
►�®iii°■■■
ONE
dine Length
notsure
yes
MEN
•p■p•■w••■w■■■■■■■■■■m■w■■■■■■■®■■■■■■
• •
:xAv?cked:
IEEE
ME
A building permit may be required by: roc t ❑ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature Please read comp ' nce statement on back of permit
A1u0 cx7 I Akw
Application Fee(s) Check #
�G r
PermitOffi anted a
Si re
II/Il�ol9 3/daoao
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
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 -
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: �osYxS� 1?0►��}
Date:
Permit #: �- SL- 13 A
Describe belo',� 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)
C V'
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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
252-808-2808 :: 1-383-4RC©AST :: www.ncco_astaImanagement.net revised:02/03/10

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DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Owner: _r f I J P
Address of Property: s � • /�ti,� t![.L /� G Z 741S 7
(Lot or Street #, Street or Road, City & County)
Agent's Name #: h/A Mailing Address: C
Agent's phone #:
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
if you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Correspondence should be mailed to 401 S.
Griffin St., Ste 300, Elizabeth City, NC, 27909. DCM representatives can also be contacted at (252) 264-
3901. No response is considered the same as no objection if you have been notified by Certified Mail.
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.)
Of_X_I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
• t W
Signature
)E013,C9T AA FE905', Al-
Print or Type Name
116 Al. Ae- •
Mailing Address
_a=:�& y
City/Stateap
-7�0(p— 4,0
Telephone Number/Email Address
Date
*Valid for one calendar year after signature*
(Adjacent rope caner Intfmation)
1W,oA1AJ il.,r1
Signature
Gam\ V,V, L'
Print or Type Name
6,fI N/tVP, 6
Maifng Add re s
City/State/Zip
Telephone Number/Email Address
1b
Date
Revised Jan. 2017

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Own,
Address of Property:
Agent's Name #: Feg ro�x5
Agent's phone #: %D 5�— 10 i3k5-2-
Mailing Address: _44,44tQ &A Alww
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are pr posing. A description or drawing, with dimensions, must be provided with this letter.
7I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Correspondence should be mailed to 401 S.
Griffin St., Ste 300, Elizabeth City, NC, 27909. DCM representatives can also be contacted at (252) 264-
3901. No resvonse is considered the same as no obiection if you have been notified by Certified Mail.
f�
i
WAIVER SECTION gB -roksz8i� 7l� xcrx <Ge—
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.
(Property Owner Information)
Signature
)E-c R7 ICI
Print or Type Name
1 iG Al. S Dx. .
Mailing Address
J1Jt&g11
City/State/Zi
'7a9-- TP 7- 3C
Telephone Number / Email Address
1b11-711 g
Date
Property Owner Information)
ri�ot,Typ ame k, l
Mailing Address
City/State/Ziih
Asa. 55.13a-3
Telephone Number / Email Address
10 /27/1°Y
Date *
*Valid for one calendar year after signature* Revised Jan. 2017

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