Roberts, Tom

I�&AMA / ❑ DREDGE & FILL
GENERAL PERMIT
tlj�eJv ❑Modification ,❑Complete Reissue ❑Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission Wan area of environmental concern pursuant to
Applicant Name ! ( �` � � ']�°. 1' Proje
N9 78953 A B 6 D
Previous permit #
Date previous permit issue
d
15A NCAC / /❑ uleshed.
:t Location: County (_ e-r
Address - }
yI-'n Street Address/State Road/ Lot #ys)
City (i u rC/ *i t State/V� ZIP.(/ S 1� !) r>l `' ' Y
Phone # M) y5 -�L ('E-Mail Subdivision
Authorized Agent r r F l City C `` ' s r^'iZIP
Affected ❑CW r�r:W PFIIA ❑ES ❑PTS Phone # ( ) %River Basin
❑OFA ❑HHF ❑IH ❑UBA El N/A nat
AEC(s): Adj. Wtr. Body manunkn
❑ PWS: '
ORW: yes /� PNA yes n� Closest Maj. Wtr. Body ✓ ✓'✓�
Type of Project/ Activity
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MEMEME
MINES= WREN
, I-. -P r
Agent or Applicant Printed Name
�K t ( I' � l
Signature ** Please read compliance statement on back of permit°
I�
Application Fee(s) Check #

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 INC 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 howto complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/1-888-4RCOAST
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, Bartle, 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 7106117

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Ihcrr q LaUV ) 12.O!DC.(-k)
Mailing Address: *f tX-" Lar"e,
G�Ioo(rsdref, HQ -
Phone Number: GJq-Jr{n(/7-
Email Address: tc)mCaDiurn�jjncAIrlu//e� �f 0. COrn
I certify that I have authorized Luici iJ0QU0Qr,/ ZINC CCDCLS(ni Rdcjal-k)n
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: fylac. 6 1 Lu f
Shr)re l,ne
at my property located at 63 1�i�,1 (', lk-jzrh t i.(w-
in 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.
Pro rty Owne fo mation: P4^ Q
")�5
� Signature
Print or Type Name
Title
�, 17 lZoz�
Date
This certification is valid through C)<3,1�/ ap-�iG

(qst`e,5ka
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to (I"ib mlaf,
located at 15 (Name of Property Owner)
property 3� LC-.
(Address, Lot, lock, Road, etc.)
on \ <<j i f0.i' _ , in LC) Cek5i- ir" N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
Io�catio. n.
=1_(, I have no objection to. this proposal,
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(IndlVidual proposing development must fill in description below or attach 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.)
1 do wish to waive the 15' setback requirement.
or
I do not wish to waive the 15' setback requirement.
!r nformation) y- (Adjacent Property Owner Information)
Si Lure*
/Co FTCTs lrzvYeJ�l' �Fa'L.S5 k casnesk,`
vr%C . ed k-)
(Revised Aug. 2014)
`Valid for one calendar year after signature'

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Tracking Number: 70190140000102315174
Your item was picked up at the post office at 2:55 pm on February 19, 2020 in
GLOUCESTER, INC 28528.
Status
Delivered
February 19, 2020 at 2:55 pm
Delivered, Individual Picked Up at Post Office
GLOUCESTER, NC 28528

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