Lacey, Fred

rlCAMA / Ll DREDGE & FILL NO 71675
GENERAL PERMIT Previous permit# A B �C' ID
❑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
LlRules attached.
Applicant Name �" `: /� ,'(( 1C �� Project Location: County
_
Address (/ �� ,> f „t / ,3I r '�i �'� ( f� n Street Address/ State Road/ Lot #(s) <
ty State JU f ZIPS
Ci ; '�
Phone # E-Mail
Authorized Agent
Affected ❑CW .(SEW _n PTA
AEC(s): ❑ OEA ❑ HHF ❑ IH
❑ PWS"
ORW: yes t ,nod PNA yes / no
❑ ES ❑ PTS
❑ UBA ❑ N/A
Subdivision
City ZIP
Phone # ( )_ River Basin ' r -
Adj. Wtr. Body f Clvy/ hat ¢mzn./unkknn
Closest Maj. Wtr. Boddy /
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Agent or Applicant Printed Name
Signature **'Ple erea compli@pce'sistatert " ton backof permit"
Application Fee(s) Check#
Permit Officer's Printed Name
Signat re
///
IssVing bate Exp{ratioh 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, certifythat this project is consistentwith 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 complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/1-8884RCOAST
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)
Washington District
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Fax: [phone]
(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

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to /-/l !7 L .9 Crr' x 's
(Name of Property Owner)
property located at ./O© GON%iv C/�fiC> A&C"Ir
(Addr , Lat, Dl cx ', R&4- cic.)
on_SAR/NG C/eca/ In Ertl eaAl_ N. C'
(Waterbody) (City/T wn and/or County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
^..a.ve 0: ec-f o ns to this p;ripcsa1.
0- ESCMMOKA%0JOR 4RAWWG OF PROPOSED OEVELOPMEU4T
(Individual proposing development must fill in description below or attach a site drawing)
.S,F.F 'T/!F A %%/d c Nk D j-1<1-1-c /4 CcA MoXi /NFaX11f1tT/aN _
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.)
1 rjr wj&h J w,, iA-- the 1J' Setba k requirement.
X I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
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Signature Si lure*
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Print or Type Name Print or Type Name
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Mailing Address Ma�{ing Ad ress
city/state2ip ' city/Statemp
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Teleph ne Number/email address Telephone Number/email address
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Datek Cate"
(Revised Aug. 2014)
*Valid for one calendar year after signature*

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A(y�pr ENT RIPAR16N PBQPERTY OWNER STATEMENT
I hemmoy certify that I own property adjacent to f r�as7 L-. c-a-Li Is
(Name of Property Owner)
property located at �t%D i % lro Ai IUD c-4 tilt -PP-
P r-te'e (Addo mz, Lot, l2liack,
on k /a i Rom= l i���7 t%R2'? K_ in IU G W'd, -ref N. C
(1Naterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
lacatio ,
M
E have no objection to this proposal.
• "c � � a �ti: vlS iG si,X }3�L,738isi.
DE SCRt4TtogJ&D?4R ORAWWGOF PROPOSED DEVELOPMENT
(Individual, proposing development muSI fill in dascripflon below or attach a site drawing)
S -L
WAIVER SECT QN
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 uniess waived by
me. (If you wish to waive the setback, you must initial the appropriate blank below.)
as urr�s'� to ur.:tip t'.s `5's:�th,;,:k r�uirament.
i do not ovish to wane the 13 setback r auiren
(Property owner Information)
Property Owner Information)
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(Revised Aug. 2014)
Valid for one calendar year after signature'

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