77663D - Keith

t-Ii II 17f Z02-6) rifryw
❑CAMA/ ❑DREDGE & FILL NU 77663 A B C O
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 7 H. . I Za o
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC 1 t
❑Rules attached.
Applicant Name DC11,9.la( VA 1`i V1 Project Location: County r ur,' 'c-LAddress > 0 oq "OQr + " 9 1+uwIt- f I a Street Address/State Road/Lot#(s) /
City A?t)( State NC' ZIP )75�9 32 Say`-S�n Orivt
Phone#(Ili )q&1 ' 9 9/$ E-Mail c keit'►'i Oa ®n C rr, Subdivision /
pM
Authorized Agent VCL/ Z1%1, . City 1- 0‘Ath &air\ ZIP ;Sii(P Z
Affected ❑CW XEW 'PTA ❑ES ❑PTS Phone# ( �� River Basin L uw
AEC(s): EloEA ❑HHF H key-
❑UBA ❑N/A Adj.Wtr. Body �av" p\ ll (nat /unkn)
❑ PW$ W
ORW: yes /,/no PNA yes / no Closest Maj.Wtr. Body L`)
Type of Project/Activity N e,ti--) Dock -'vk�{ At-I(I'�J
J /V (Scale: (,%.. 2,0\ )
Pier(dock)length I
/ ISXl7 i j I
Fixed Platform(s) . t.., "' 1
I � � �e
Floating Platform(s) X ! J i i
1
Finger pier(s) 1 CAI,IA
r .......... ' - -- -_..........._....._
, _
Groin length - ! }
number / j --.. 1
Bulkhead/Riprap length ? - ! } { --
I
avg distance offshore I !
i � f �
max distance off re I - - i VN.Q-e
Basin,channel 1 t� 1 WO'Profs;
' i\°(
Vor
cubic yardds 1, 44,
Boat ramp % ` 1 „ `. } J - r
Boathous- 6 X\'D i - - �_......._..__._._
i --
a
-
A'4X
Beach Bulldozing �1 . 1 i16e I !
Other f* 1 6, ,In 1 ' !
I w' 1 j ,.weir
Shoreline Length 5 0 1 ' I _ i 1 I 1
I
SAV: not sure yes no }v.i li- j - a
t. ( _ N0
Moratorium: n/a yes t..CZ - 1 t 4 , , : .
, , ., ,
1(.it--
Photos: yes ` - ~- __
ISL
Waiver Attached: no 'S G S
I34S
A building permit may be equired by: I 1)l(i Q,1/1 Bel(J . n See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)(�1
Notes/Special Conditions / '`\ v 1A\e S 04 7 4-. 17o() ) 0 c.,a( / c-et-f-[/ vied -/ al(Ya 1 reA 1..4 I c C.'
apF\ i No w,dtx c& C` bvey Gca-c tt\, wefi\6Jo n(k eX/_PPo( Citrd'�4fr o
1.v-%-O f "Nc(\ i 'k ' atc l►�1 f cili - 7 Clip ! e✓riA
o •
0(/_ , ,A,) tiA,„,,c„,,c,_
0,,,,\L
Agent or Applicant Printed Name Perm' icer's P ted Name
Signature **Please read compliance statement on back of permit** Si ature
V00. 0 0 -—7cj ( -7 )o)fl)aoo 9h9- a-o l
Application Fee(s) Check# 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 (252-946-648 I) 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- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

IIIIIIIIIIIII III IIIIIIIIIIIII 11111111 84119 P0932 10-03-201002
Brunswick County, NC Register of Deed Clemmons PROP
page 1 of 2
yne ►i1� -
�� Re' Ij�( -Int.
Ck '" ►/
s # ""l v 1� cash$
_ Cash$
Finance_
nrtione of document are illegible due to condition
t :.ur"nt contains seals verified by
arfyinal
:^at canr-, reprod,.,•Nu or
copied.
Prepared by: Richard F. Green,Attorney at Law (No Title Examination or Opinion
Requested or Rendered)
STATE OF NORTH CAROLINA
INSTRUMENT OF COMBINATION
COUNTY OF BRUNSWICK
This INSTRUMENT OF COMBINAT as r ired by the COUNTY OF
BRUNSWICK is made this the 2-°k day offer, the year 2018. Whereas
Douglas Gray Keith & wife, Shirley Franklin Keith are the makers of this instrument,
and wish to combine 2 tracts of land into one for the purposed expressed herein.
THAT WHEREAS, the maker of the INSTRUMENT OF COMBINATION owns
certain properties, parcels, or tracts of land, all of which were duly recorded in the
Brunswick County Register of Deeds Office,more particularly described as:
TRACTS ONE:
BEING ALL OF LOT NUMBER TWO HUNDRED NINETY-
FIVE (295) OF THE HARBOR ACRES LAYOUT FOR
COASTAL DEVELOPMENT CORPORATION AT HOLDEN
BEACH, BRUNSWICK COUNTY, NORTH CAROLINA, AS
PER PLAT THEREOF BY C. B. BERRY, REGISTERED LAND
SURVEYOR, DATED JULY 30, 1965, RECORDED IN MAP
BOOK 8, PAGE 13, IN THE OFFICE OF THE REGISTER OF
DEEDS OF BRUNSWICK COUNTY, NORTH CAROLINA, TO
WHICH PLAT REFERENCE IS HEREBY MADE FOR
GREATER CERTAINTY OF DESCRIPTION. BACK DEED
REFERENCE BOOK 4062 PAGE 0647.
TRACT TWO:
BEING all of PARCEL B (280 sq.) all according to a map
entitled "Recombination Survey of Lot 295R", prepared by
Gary Gurganus Land Surveying, dated June 5, 2018 and
recorded in Map Book I10 , Page Q.5, Brunswick County
Registry.

P)11;115::14/4724
3 '0-29-2018
I IIIIIIII'ltI�IIIIIIII�IIr of
Brunswick County,
issuance of improvement permits by governmental authorities and shall hereafter be
considered one parcel of land and referred to as:
BEING all of LOT 295R all according to a map entitled
"Recombination Survey of Lot 295R", prepared by Gary
Gurganus Land Surveyi , dated June 5,2018 and recorded in
Map Book 110 ,Page at ,Brunswick County Registry.
IN WITNESS WHEREOF, this limited special purpose instrument for the purposes
specified above and is not a conveyance of ownership in any way; the makes have
hereunto set their hand and seal, the day and year first above written for the purpose
expressed.
(SEAL)
DO
L)
i SHI] EY FRANKLIN KE
STATE OF NORTH CA LINA
COUNTY OF BRUNSWICK
I certify that the following person(s) personally appeared before me this day, and
(I have personal knowledge of the identity of the principal(s)) (I have seen satisfactory
evidence of the principal's identity, by currents e or federal identification with the
principal's photograph in the form of a 1 IC dr sT5 LIC-c o q�r ;''�,,, ) (a
credible witness has sworn to the identity of the principal(s)); ac o t ledginn 44`tpe that
he or she voluntarily signed the foregoing document for the pure stated therei. d in
the capacity indicated: DOUGLAS GRAY KEITHAND SHIKLiT41 LIN11 ITH.
�cz PUBLIC 0
D12g1 1�Date: l /AG
(OFFICIAL SEAL)
NOTARY PUBLI
lit1 poz rui ion dales

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: DD LA Las Ke .-N1
Mailing Address: 3co4-4 ou.ri'n9 1-16k-uJte_ Pt.
. NJ - ° 3t)-7
Phone Number: gig -g - °I L'V g 61 9$
Email Address: K .i- -, 001 r% rtc-• rr. CAa-YrL
I certify that I have authorized Y Cal c_.
Agent/Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: CAV,jtt_cA aac_k_
at my property located at I?2. Dr. I l L -.- &ac!-t
in I ru iSwcc k. County.
I furthermore certify that 1 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.
Property Owner Information:
i\G
14
Siig ature`
LtAkS
�J Print or Type Name
vJ n
Title
I o I `1 / 2°2-0
Date
This certification is valid through

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to D wj (aS I4L`'1n 's
(Name of Property Owner)
property located at 13 a Set l I 'R5I'` 112 ►
(Address, Lot, Block? Road, etc.)
on CAA& \ , in t4oldcn '. aCi , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locati .
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)
the d
CoVe IttA bock_
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 yo h to waive the setback, you must initial the appropriate blank below.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Info t' (Adjace Prop Owner Information)
Si ture 4 Si ure* i2 , C/ �1
Print O Oyp Nan'ie O� Prim pr ypa.Na e
Ma.ing Address c2 45.3 Mai' A r s
City tat /Zi I City/Scat ill eAf /C 4 9 Mar ) .0 q 3 3 6,0 0
Telephone Nu ber/emailaddress Telephone Number/C} em il�ddress
.� vIN /
Date Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature*

t.. % .. •
• l

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 's
Name Of Property Owner)
property located at 13 a &I l iS 1 U_
� (Address, Lot, lock, Road, etc.)
l.�a-`
on n a ` , in 1 e" Q CJc , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatign.
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)
5-e Ar41Adeitd 6ke-k4 )
Dock,
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 y ish 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.
(Pro rty Owner In rm tion) (Adjacent Property Owner Information)
Al2,4kask ,9)it)
�St na Signature* 1
O MKS 5V rley \Let- . n aL V. Ck S Y1
Print or p Name Print or Tye Name,
b 4 So a il„u r` k-'Q\ 13 �c S„n ‘i1 S 11
Mailing Address Mailing Addressxx � L a45-39- 6130-1- o\der\ each N aelco
City/S e1 G 99/r City/State/Zip
t*, 9
/ J iL apt,. �is,2, 3 �C.�4
Telephone Nu berr/ mail address Telephon Numb /ema I address
o ay Uzv o 1 a g7ao a O
Date Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature* 3
L DLL $6— Sa t I- i K1

OPlippip5)
U
04:41L
r
d
k
O
U

Check
Dote Received Date Deposited Check From(Name) Name of Permit Holder Vendor - Check Number amount Permit Number/Comments Receipt or Refund/Reallocated'
,
Cokartnl Column? Column3 Column) Column5 Columns Cokunn7 Columns Columns
10/27/2020 Lighthouse Marine Construction,Inc. Jeremy and Shelly Norris Coastal Bank and Trust 3445 $ 600.00 GP/77673D JD rct.11770 __
10/27/2020 _ Lighthouse Marine Construction,Inc. Vance Wade Coastal Bank and Trust 3444 $ 200.00 GP$77872D JD rct.11789
10/27/2020 Richard Penny Construction,LLC Scott Sutton Navy Federal CU 1171 $ 200.00 GP#77671D JD rct.11768
10/272020 Laid to Sea Construction,LLC Felice&Richard Brenner FCB 317 $ 200.00 GP 0,77686D KE rct.12406 _
10/272020 VCC,Inc. Scott Ussery !BB&T _ 7919 $ 400.00 GP i77662D Ben rct.11720 _
10/272020 VCC,Inc. Deborah Fish BB&T 7918 $ 200.00 GP#77661 D Ben rd.11722
10/272020 VCC,Inc. _ (Douglas Keith B68T 7917 $ 200.00 GP8776630 ;Ben rct.11721
10/27/2020 Jeny Ennett (Bruce and Patsy JoneS Coastal Bank and Trust 3411 $ 400.00 GP#73582D 1JD rct.11771