William Clark Living Trust

❑CAMA / ❑ DREDGE & FILL M 78974 A B C D
GENERAL 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
O Rules attached.
Applicant Name ! c74 :•1 1 t Project Location: County
1. r,
Address (� : ' - X! tr f':.,� �'_ �� ! Street Address/ State Road/ Lot #(s)14
City`� ()il , ,\ �` State/n ZIP_ (l�
Phone # E-Mail Subdivision
Authorized Agent 1. 1 1 1 (t a 1 City ZIP -
Affected ❑ CW ❑ EW ❑ PTA bES ElPTS Phone # ( ) _. River Basin %�! '.iA c,)e-_
AEC
(s) : El❑ El OEA HHF IH ❑ UBA N/A
Adj. Wtr. Body �� i L'`C'�l (nat man /unkn
❑ PWS:
ORW: yes /, no PNA yes / no) Closest Maj. Wtr. Body `""'" ' i C'%'
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
Application Fee(s) Check #
v it�/1C'
Permit Officer's Printed Name
Signature
a
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 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, 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/ 1-888ARCOAST 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

PERMIT FOR PICK UP INFORMATION
TO BE FILLED OUT BY THE FIELD REP TO ATTACH TO A PERMIT FOR PICK-UP
FIELD REP NAME (Please print): Brad Connell
1. Date (the date the permit is placed up front for pick-up):
2. Name of person picking up permit: Brandon Stallings
(the person you called to tell them the permit was ready for pickup)
3. Phone number of the person picking up the permit:
670-0478
4. Permit fee amount to be collected. Paid in full
Specify if the person is one of those who must Use Money Order Only
5. Month of Expiration: July
NOTE TO ISSUER: The expiration day will be the same day as
issuance.
6. Other information needed or instructions. N/A

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to s
s , , (N me of Propelly Owner)
property located at
�Haares:
on m{,,a,� —/ &N -C,( in
(Waterbody)
(City/Town 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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Pr perry ner Information) (Ad' /oe O er n rmation)
1'�iL - �
t at T 1 ture / /
v K C/ rCAAV p `^ti I r/.)C/l //V 1/G%5=41
Print or pe Name Print or Type raS►�
M ilin Address Mailing Address
CitylStatelZid Ci 1State p
Telephone Number Telephone Numbe' r
.3• lb, a -a aO 3--'aicy00
Date Date W5(('115JRVl
(Revised 611812012)
MAR 19 2020
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 4�� q VlQ' �v`C s
1 . , _, , , . (N me of Propel Owner)
property located at
1Naaress
on M{_/Sti , in
(Waterbody)
(City/Town 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.) �
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Pr perty �ner
Information) (Adjacent Property Owner Information)
tg at Sigf ature
Print or e Name Print or Type Name
2374, Srs-05611 ^-0K /e, t-- c�lTy �.a iVe
M ilin Address Mailing Address
v v(,nl 4 At 3&932r'
City/State/Zi City/State/Zip
33-1--- 1 gy • 355 <9 e i/. - -s -4 3
Telephone Number Telephone Number
Date Date
(Revised 611812012)
MAR 19 ?a
10CM-M U UIT Y

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AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit:
Mailing address, 2 3 ;V�.ovJ 5 b� M LA
Telephone Number: 7J 3 7 19 Z 3 5 S O
I certify that I have authorized /�;_;,,9,. /f �; 1,_;,,��{;^� (agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of
at my property located at J L f ' -3 K ► t45 Cr�t'C� b r\-'� ,
This certification is valid through
(Property Owner Information)
Signatur
Print or Type Name '
Title, co. owner or trustee for property
�0?0
Date
33�- Aga--35S9
Telephone Number 1
Email Address
(date).
Ltj(GM-MHU GLTY'

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STALLINGS
LAWN cA
AloWINc
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G AND EDGING
MULCH & PINE STRAW
BUSH HOGGING
BRA 2 6 STALLINGS
CALL FOR 700478
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