77766D - Clark

`CAMA / —DREDGE & FILL No. 77766 A B C
i-1-11
EN ERAL PERMIT Previous permit#
New JModification iComplete Reissue liPartial 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 I 5A NCAC v 77 • (ZbU
//� �� / Rules ched.
Applicant Name �O/2 71 „✓a ‘ (-7 d IL-- Project Location: County
S
AddressWI
2/ 3 9 Al ' t7- 4 u/ 5l - Street Address/State Road/Lot#(s) I
City 4 I Gvyi a /,/ State//4) ZIP 4,712z— /((/2 /"/I r D� `"_.1- -
Phone# pf-]) q3/- 7 /E-Mail Subdivision
Authorized Agent , A-1- Fe,r, __l G«.# City / e"/O t.,-. ' .4, ZIP z 8'YY t
Affected ❑CW [ C PTA ❑ES ❑PTS Phone# ( ) River Basin �'U
AEC(s): CIoEA ❑HHF ❑IH ❑UBA ❑N/A Adj.Wtr. Body 4 /Ji man /unkn)
❑PWS:
Closest Maj.Wtr. Body i'4 _2//r 1/
ORW: yesi PNA yes.M Type of Project/Activity i7-64,1. 0 v-v 1/ t.b4.4 e ' /r 5/,// 5-4 ul`i
0 4 7 1`1>r t^, (Scale: f.. / )
Pier(dobk)length i
Fixed Platform(s) t ._hid J i f I f
Floating Platform(s) i / I i "JJ
—j I •- I. 1 I - I
�_. _.__......
Finger pier(s) _,
Groin length L
? i F41
, ,
_ ._._._ 1
1
Bulkhead/Ijiprap length — - i •ir 1
avg/distance offshore MEI frr-f itilfi •
_
mix distance offshore l , • ,�y
Basin,channel — I
i i -'� I I.
i — - t
,
cl\bic yards i i .....
Boat ramp m C i i - -
i V
Boathouse/ tlift -.__.._-.-I-._ .. {._.._ _ ys. __.. i:�.
I f
Beach Bulldozing ' -
W
I
Other I I
i • i
it l
f asuQ
Shoreline Length /' (� �.'�-+ f� � _ _ • I j0 Y '"
SAV: not sure yes -4-/ I
Moratorium: n/a yes i I
Photos: yes iiiii. --_—..._ - -—.
I Waiver Attached: yes 4
A building permit may be required by: 1(:)/e4-a:, 6-ei- . ❑See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions
77-g-1-1 /144.--'ff.-A----- ,lt- /Ifil"--.
Agent or Applicant(ri Name P it icer's Prin ed Name
X
Signature `Please read compliance statement on backpf i e* Si ture
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 (252-946-6481) or the
Wilmington Regional Office(910-796-72 15)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

ENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
• Complete items 1,2,and 3. A. Signature
• Print your name and address on the reverse x CI Agent
so that we can return the card to you. __ �" ❑Addresse
• Attach this card to the back of the mailpiece, B. Received by(P'nted Nprge) C. Date of Deliver
or on the front if space permits. Jv e
1. Article Addressed to: D. Is delivery address different om item 1. 0 Yes
If YES,enter delivery address below: p No
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61ePn25,49-r-0� ilk aZ Z 1/oj
II I III'I III ,II III III I I I III I I I III
I I 3. ServiceAdult
igType 0 Priorityei Mail Express®
0 Adult Signature ❑Registered Mail'"'
❑Adult Signature Restricted Delivery 0 Registered Mail Restrict
9590 9402 5695 9346 3105 95 1gCertified Mail® Delivery
❑Certified Mail Restricted Delivery 0 Return Receipt for
❑Collect on Delivery Merchandise
2. Article Number(Transfer from service label) 0 Collect on Delivery Restricted Delivery 0 Signature Confirmation,
❑Insured Mail 0 Signature Confirmation
020 1810 0001 1337 2994 Insured Mail Restricted Delivery(over$500) Restricted Delivery
no r.....,-. Q 01 1 i..i..nn-1 a nn.,,cnn nn nnn nncn n,,...n�i�,.oew. ,,Qo�o�.,•

UMSgnilittiabtMaRL3
First-Class Mail
111111 I Postage&Fees Paid
+I USPS
11
IPermit No. G-10
9590 9402 5695 9346 3105 95
United States • Sender: Please print your name, address, and ZIP+4')in this box•
Postal Service
g/4r ecO 7k4.
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247

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION r" E.iv E
JAN 12 2021
Name of Property Owner Requesting Permit. Robert & Sarah Clark
Mailing Address: 2039 N Delaware Street
Indianapolis, IN 46202
Phone Number: [phone] or(910) 899-0456
Email Address: sarahskipclark4a)gmail.com
I certify that I have authorized Hal Fogleman / Allied Marine Contractors, LLC
Agent Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA. perm,-s
necessary for the following proposed development: Removing the floating dock
and replacing it with a fixed dock in the existing footprint
at my property located at 1162 Monroe Lane. Topsail Beach. NC 28445
in Pender County
! 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_ 6
Property Owner Information:
/� �/�
e
Signature -�---
Robert M Clark III
Print or Typ' Name
i itle
08! 17 1 2020
Date
RECEIVED
This certification is valid through 8 ! 1 7 / Z
JAN 1 2 2021
DCM WILMINGTON, NC

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JAN 1 2 2021
6r
v LD DCM WILMINGTON, NC

. ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS/BOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to RoSerf P 5'' t C/1 r/< 's
(Name of Property Owner)
property located at /f 1 2 Mon ro
(Lot, Block, Road, etc.)
on CP(44? , in / 0 ya1'( dCCG&- ,N.C.
(Waterbody) (Town and/or County)
Applicant's phone#: l0 3(07 02( i Mailing Address: 92 1A rO/& Gf•
Mt er,p4 f eevr.Q/tC 24.443
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings/boatlift/boathouse
must be set back a minimum distance of fifteen feet(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 not wish to waive
yI do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
'7ee a/1/i c � RECEIVED
JAN 1 2 2021
DCM WILMINGTON, NC
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
7o3grA. a elg ware sf, - , h.,(INAc,vtki
Mailing Address Signature
TrItailor ovs IN 44 20 z � - t� - (\(\c-
City/State/Zip Print or Type Name
3/ 7 - 43/- 589/ —11 1 11
Telephone Number Telephone Number
\VI-1)(10A
Signature Date Date

4 reW+'c a s`€. ,s,cir tt H'rt-. r 1 r?x `'a1f* -hr •1'-�A`; :13.' `9A•w ' ' •,. -• ,;li}fid••1 y, " •Qr'Sr' 4',f 0 ht) s" T;i DIY
F>r, (7 STATE OE MTOIaTH ('11iZOL AT.A 0 x ¢ ;
•; CERTIFICATION OF VITAL RECORD y _
J. r.., .t- :': ..:- "�c" ti;-Mf Yak' ,��a�,<; ;;-4( i1@�1r %�7r.;�o 1 nQU��, ri!!� a�tfi H ",�. �\f
% - )RE " JEFF Le THIGPEN ( ,
!� GUILFORD COUNTY REGISTER OF DEEDS \ .„. i __,,1,i^ •
_ -
,T E ` I I ')9-
��.. Il li 11111 Ill II hh II II IIII I..ti 1 I Li
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES '•
�Pi" N.G VITAL RECORDS j
! REGISTRATION _ )�'� CERTIFICATE OF DEATH 2020903519
,. ` DISTRIC?NO.-(.�Lr `[.) LO ALNO. COUNTY OF DEATH Guilford STATE FILE Nip D 308 1918 i�
4A.. 'a.,. . DECEDENT'$LEGALNAME - .--. - __ ._-_ -_
'` TYPE/PRINT IN
to FIRST la MIDDLE 1c.LAST fd.SUFFIX le.LAST NAME PRIOR TO FIRST- I�rS'
MARRIAGE j iE''N, PERMANENT
BLACK.
BLU ORE. Edward Linn McVey III
'tC` BLUE INK ,Ake eke , i�
eF:t 2_SIX 3..AGE-UST '3b.UNDER 1 YEAR-3c.UNDER 1 DAY 4.DATES?BIRTH(Montt/Day/Year)5.BIRTHPLACE 0,DATE OF DFI.THMorWvoaNear 777
._, &RTHaY(vnl Monihe Dip. 'Mona Minutes (Coney/SI,r Foreign CourGy) ( y ) ;-
M 72 05/01/1947 Columbus, 03/11/2020
YJ�' �0 ,_ e. DE£QOCC OSPITAL TO-IF-DEATH OCCURREDSVMENHERE O
yl a InpaeerK❑ENO'npau.nl LE DOA a Hospice 1.0499 0 Nursing term care�uMe U pautlenrs Rome DOlher tSparlM
e_µ�'. 3 7c.FACILITY NAME BI,rc insetuNO4 give sb.eT end number) 7d.CITY OR TOWN Yet.COUNTY Oh OEAT1I - `
Greensboro Guilford ; .
;- Greensboro •S.SURVIVING SPelUSE(Give name iba.DECEDENT'S USUAL OCCUPATION 10a.Kum)OF BUSINESSUNOUSTRY ,
0Memisd [lMarn4d.but toparatedl]YMdowed Ow lc Vol ma/OWN (De not wee refired)
• 5.1 a Ei DNrcad ONever monied DUnlmown �''
e Catherine Boyd Lawyer Real Estate 'V
`` 1 It.SOCIAL SECURIYYNU3.(BER 12a.RESIDENCETATE OR FOREIGN COUNTRY 12b.COUNTY 1Sd,CITY OR TOWN. - t:_
' e a 292-42-9133 112a.
North Carolina Guilford I Greensboro
{r,. ;124.STREETAN n FR `t:..,,,.:.::,, _;s,.o �r COD.- rs wssOECEDENT EVER IN ..
4
0Y.t ❑No US.ARMED FORCES'!
1 1818 Cannel Road 127408 , Q(Yee r]No •
a'' h 14.DECEDENT'S EDUCATION(Check the boo that 15.DECEDENT OF HISPANIC,ORIGIN?lack The tit.DECEDENT RACE(Check one or more races to h4icaro what the
.1:..' Lc boa!describes thehi5heal Degree or level N school boa Nat best describes wheMN the 60ccdenlle decaaer4 oore+drae Mmsdl or cam el to be)
i; I completed at the Iye of death) Sec rsM MpanlULao e.Check Me-No.pox if 0 While p Other Mien(Sparely( X..' p8tn wade or fees depdenl Is nal SpeNWlt'apo s&oluro) 0 Mack or African American
�)0,{ ❑11h-12N race(nadpw+. m No,not SpanI;M9spaNciLaano (]American lnaanrAlaeka CI Relive HawAIan I.
'rmd','k I a 0 High school graduele or OF.D completed p V..Mexican,Mt/Noon American Clesere _ =
Some college credit,but no degree pals.Puerto Rican pincl4*Native(Name
late cr the ervoVW r pSamo.o Gowns n tan or Cb.nOrro
$; CJ A1109MIe degree(e.g.,AA AS) ❑Yes,Cuban ) 0OtherP its'^
A' u1 p Other PaBOc Islander
@ peauteinra agree(rig.,BA,AB,BS) pen,other SpaNaM-liapanlotetino(Specify) (Seedy)
FF; z 0Master's degree le.e.,MA,MS,MEng,MEd,MSW.MBAI ['Akan,ndan ❑Japanese
` C I 0 Doctorate(e.g.,PhD.Edo)r Protesslrv)degree - 0 Chinese p Korean Oaths'(Specify) I -3:
'•1 t I3 FII pine ['mellowness.(ag„M0,DOS,DVM,LLB,JD)
•Y .I ®57.FATHER/PARENT NAME(Feel,Middle.Last)(Last Name Odor to Fool Meddle.) 18.MOTHER/PARENT NAVE(FOR,Mdde.Last)(Last Nome Prior io First Manioc)
�j Edward Linn McVey,Jr. Ir nit$nen.c !%'
xrfl" i is..INFORMANTS NAME w TtSb.RELATIONSHIP TO DEC .AL4&J DASDkFSS�tEreet and Manbr,Coy,Slase.Lp Coos) i '
Catherine B.McVey Wife 181 S Carmel Rd,Greensboro NC 2 40R-3120
EE J
l"ICI o 20a.METHOD OF DISPOSITION el Basal 2)Cremalicn 206.PLACE OF'ISPOSITION( ems rcamelery.aemalory. 2ac� (City Town and Stele) �A
•S. I ❑Donation 0 EAtombmenl p Removal from State oNr Place( I
-.;..I Westminster Gardens Crematory Greensboro,NC , :
s 21. '�NATURE OF NE`�L DIRECTOR 21b.LICENSE NUMBER 21c-NAME-OF EMOALMER 21d.UCENSE NUMBER
' i �1 a�-L I FS 2601 Not embalmed
t, f I ' HOME Hanes Lineberry Funeral Home lit
I 515 North Elm Street'Greensboro NC 27401
s.; •.,,ci,rn 23.Pan I.Enlist the fRan of evele(diseases,elates orcompiu�ru)Thal dkecrly coos the des i ran w,err dnr ends sue as cardiac aneel, Apprmdmale Intern! s
;e.g.;I t u.it.irnuwr respkelory erren!,er ventricular lon:lotion without showing Ow 0116 lbws
05y on ls b.0 and/Oraw d.Enter only one e on•ens.DO NOT ABBREVIATE. Onset to death y:
y
IMMEDIATE CAUSE ,1✓ r5�A rA1-r�r/ �/
3 (Fetal di Or condition (car U'LAP r11 j V I� (�r�•. S I)_1
;�E �D€ raJary n death) � � dtu�S Q ras.eeue,rce Dry rs I
t,;6l ii 2 1 Se4uenody 1st cadnnna
ffi,E cause
Y b.
i 2.g acted on line clo a.g eo the the LAte to(or u e canaaptenoe op
rt I ,) UNDERLYING CAUSE,ilta
1 �: S or rim Net Due to(or as a consequence Ives.
initiated the events rawcng
?'. 1 P, b r deem)LAST d _`
�: �; a PART IL gd0gle_Satn but not rosidng In Inv Lndenying 24a.WASA.N AUTOPSY PERFORMED? 24b.WERE AUTOPSY FINDINGS AVAILABLE )'
I.
1 el g € „ causepven inPAR , ❑Yes No TO COMPLETE THE CAUSE OF DEATH?
--:'3sl a 9Ee pees ❑No we
'T• 'I I 26.MANNER OF DEATH 26a.WAS CASE REFERRED TO 27.TIME OF DEATH 28.DID TOBACCO USE 26.IF FEMALE: :.;
m g prN•Nral QFbMsld. MEDICAL EXAMINER? (Approximate) CONNTwturtETODEATH?
'qs" 9 1 it 17Pregnetw al lyric N O.eN
:S- DAuJd.N QPenehq Oyes,No 0Yes (Probably 0 Not P'.8nanl wahlt peel year
.' E 0 SWslde (]Cann'be 26b.IF YES '7� �/) 0N0 to Unnnown El Not pregnant.nA pregnem wnlin 42 days r deeds
` deletmin.d p 0.can.d Op Medc0 4✓'VO
'y! I ,.4 50,0 ['Not pregrunl,but pregnant al days to 1 yew&ewe assay
'zi`j f1 Unknown it progn w w+dm ins past yes I t:•
�,. 1 30.DATE PRONOUNCEOT31e.15AI(OF INJURY)31h.TIME OF I21 e.INJURY AT Vv0RK7 3•d.P'_eCe(tit Leto wv.•......,,.._ _ _ - fr•..,._..,.,+.__,:7,•,,J s
All!,
I i,..i.xi..,.y,•�r,i I (n.oro-...aylt oar)I' ....,:Hr 1 ❑Ye. 0No testacy.office,bWbry.ern 89ECJFY:. . L IA
' 1 MEDICAL podvolop.,.w I
i EXAMINER OP....ngr r_
':I ONLY 311.DESCRIBE HOW INJURY DCCL.RRED 316 LOCATION OF INJURY(SlreauNumWI/CireStN.) ❑Ped.elnn
p Other(Sway) I�.
11=23111(32.CERTIFIER(Check only one) 's.
C.niryIng phyelsien/nwN precaeoner/pRysidan aeehiarn-To Psi bell r ny knowledge,death occurred et the time,dela,and pace,end ILO a 1M ca ee;t)end manner Meted I":
Medical Examiner-On Iha ba4.or examination.andsr Ion.4r5etices In my opinion deer o curial el the Um.,date,end piece.and due loth&cans s))eM motor elated ' -
. 33a RE TITS CERTIFIER 33b,LICENSE NUMBER 336 SOT I -
i nth, . 200"1''Nil)1 »� � Gr i0
.S` 33d it N{F�{S CERTIFIER Prins vbly) a,I 4 I 36.DATER 0 STATE ' i
' �7 •\ I C. 1 �. i.}LO ?s. rK ' lJD' 711.Y /Y L_.. :
:e.., L A R N sy w •
E F;'i( ay Substitute Por DA1 E E ( r �TE�r(S E T R��-
:� 1 n„MS n,,.teo 11r1017, DATE AMENDED)Mo/Day/Yr) I rEM(S)AMENDED: �i
Nc.,m*L Ra0ARoa 41V
I ,.
;y h
` I HEREBY CERTIFY THAT THIS IS A TRUE AND ACCURATE COPY WHICH APPEARS ON RECORD IN
THE OFFICE OF REGISTER OF DEEDS,GUILFORD COUNTY, N.C.IN BOOK 308 PAGE 1918.
F (I WITNESS MY HAND AND SEAL THIS th OF MARCH,2020. nrrn,,,,,
FORD COG F t.. TH/cip''�-: ?
2 J r•4" ti� JEFF .THI EN,RE IST OF DEEDS �`` '�G1STF'��
BY: OF
"* L is
.dui- * A UTY REGISTER OF DEEDS •
8 \. e.0••' ....
5,,�9ry O.' - CSG Vital Records Security Paper THIS DOCUMENT CONTAINS AN ORIGINAL WATERMARK •yp�. y'4 �gyi P' . [7...........
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• . ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PI£R/,iMOORING PILI.iGS✓BOATLIFT/BOO TNOUSE)
I hereby certify that I own property adjacent to Igo V hark. i 's
(Name of Property Owner)
property located at MO Mo Z ifl fi n roe- L r!
(Lot,Block,Road,etc.)
on 5 t •1 - .in I f1f 5ex, ( 6(6't. .N.C.
(ti%aterbodt) Town and/or County)
Applicant's phone#: Mailing Address: 2 o3' Ill• ar-e
He has described to me.as shown below.the development he is proposing at that location,and.I
have no objections to his proposal. I understand that a pier:'mooring pilings/ boatlift/boathouse
must be set back a minimum distance of fifteen feet(IF)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 Rio not wish to waive
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
,
-t✓ a✓ amain
p ropcS-C / L,ti-ram fay , - 6 e 5c 'ne.
ity
(Information for Property Owner Applying (pariau P operty Ow - ormation)
for Permit)
'7Z Mccol& C --
Mailing Address denature
�',,�,/ ,vc d y�3 L ; ' /v
/-1.-f%4‘,C_._-
City!Statel� / .r. t or Type Name
3to 7 o21 sq /i7 d
Telephone Number Telephone Nun
Signature Date •

Char* '
Data R.c.iwd Date Deposited Chaek From(Name) Nam.of Permit Holdor _._ Vendor 11/ amount Permit Numbor/Commenta Raoalpt or RNund/R..docand
COlumnl Cdumn2 Column.? Columna Columnd Colum a Cdunn7 Colt/mad Coltman? •—_
2/9/2021 Allied Marine Contractors LLC Laura Olsen FCB 9832 $ 400.00—GP 677742D JD rct.12387 _
2/9/2021 Allied Marine Contractors LLC Nancy and Bob Carr FCB • 9831 $ 400.00 GP 677743D JD rct.12386
__2/9/2021 _ Allied Marine Contractors LLC Robert and Sarah Clark FCB 9758 $ 200.00 GP1177766D JD rct.13622 _
2/9/2021 _ Sea Dog Marine Construction,LLC Donald McVickers First Bank _ 1230 $ 200.00 GP#74368D Tmac rct.13592 _
2/9/2021 Sea Dog Marine Construction,LLC Christine Cichan First Bank 1233 $ 200.00,GP#77804D Tmac rct.13595
_2/9/2021 Sea Dog Marine Construction,LLC Edwin and Wanda Tudington First Bank 104 $ _400.00 GP#77540D Tmac rct.13594
2/9/2021 Coastal Marine Piers Bulkheads LLC Mark Sirgo Wells Fargo . 23717 $ 200.00 GP#76182D _ PA rct,11583
219/20211 Coastal Marine Piers Bulkheads LLD Douglas Home Wells Fargo 23718 $ 400.00 GP#76176D PA rct.11584