McCoy, Scott

1-1 CAMA / El DREDGE & FILL 78909 A B C D
GENERAL PERMIT Previous permit #
El New ElModification 171 Complete Reissue E] 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 rea of environmental concern pursuant to 15A NCAC
E Rules attached.
Applicant Na - me Project Location: County
Address 1
Street Address/ State Road/ Lot #(s)
City.
State I ZIP
Phone # I,Mail
J,
Subdivision
Authorized AgentCity
ZIP
0cw
E�Ew
NIPTA Ll ES El PTS
Phone # if Aiver Basin
Affected
h AEC(s): 6EAEl
HHF
PIN El USA 0 N/A
Adj. Wtr. Bed (nat /man Junkn)
El PWS:
,
ORW:
PNA..�
i
Closest Maj. Wtr. Body
yes n o
e y no
Type of Project/ Activity
. ... .....
(Scale :-----
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(q-. Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
cubic,
Boat ramp -
Boathouse/
Beach
Other
Shoreline Length
SAV: not sure yes /no
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no
A building permit may be required by: i i I ji
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit**
Application Fee(s) Check#
El See note on back regarding River Basin rules.
Permit Officer's Printed Name
Signature
z i
lssuingbat6 Expiration Date

NC Division of Coastal Management
HurricaneReplacement/Repair Request Form
Date of Request: o;.17
Property Owner Name: S c'67 -7 as' 3 1S
Address of Property:
Telephone Number:
Type of Work:
NOTE:
• The Emergency CAMA General Permit 2500 is for repairs and replacement of water -
dependent structures damaged because of a Hurricane. The replacement, reconstruction
and maintenance excavation activities shall conform to current standards and rules. All
work under the Emergency CAMA GP 2500 must be made in the same footprint of the
previous structure with no additions, expansions, or enlargements.
If any portion of a structure being replaced is within the 15' setback of the riparian line or
access area, signatures of the adjacent riparian property owner(s) must be obtained
acknowledging the notification and waiver of the setback on the forms provided by
DCM.
• Any maintenance excavation or dredging requires signatures of the adjacent riparian
property owner(s) on the notification forms provided by DCM.
Signature:
FEB 13 2020

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