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/LDREOGE&FILL
NER/AL PERMIT
LlModification I Complete Reissue [ ]Partial Reissue
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 l5A NCAC,i\J,.,
Proiect Location: County
Previous permit #_
Date previous permit issued-
11 /
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T tvtApplicant Name
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StateA ll ztP
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SubdivisionE-Mailt ,(
Authorized Agent
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Phone # (
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Closest Mai. Wtr. Body
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Basin-lclvAq9lted ,o-AtC{s):rl PrrYS:
onw: 1yl / no
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Type of ProiecV Activity 7X/(/1
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Pier (dock) lentth_f
Fixed Pladorm(s)
Floatin! Pl4form(s)
Finger pier(s
Groin lenSth
B3sin. channel
B€ach Buluonng
Other +-t-t-f-t i i
Shoreline LenSth l0ou
SAV: not sure
Moratorium: nl^
yes Jo
4ln Dl..
A building permit may be required by:
( Note Local Planning Jurisdiction)
-,,/ , _4 See note on back regarding River Basin rules
LL-"Notes/ Special Conditions /\ <> rt ),/ v l-,/ -^<Jt, ! Z
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Asent or Applicant Printed Name
+* Please read com pliance statement on backofpermit +*
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(Scale:, I - )
BulkM/ Ripr.p lenSth I
avt disteice ofthore_
max dili2nce ofrshore_
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Statement of Compliance and Consistency
This permit is subiect to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subiect the permittee to a fine or criminal or civil action; and may cause the permit to become
nulland void.
This Permit must beon the proiect site and accessibletothe permit officerwhen the project is inspected for compliance. The
applicant certifies by signing this permit that l) prior to undenaking any activities authorized by this permit, the applicant will
confer with aPProPriate local authorities to confirm that this proiect is consistent with the local land use plan and all local
ordinances, and 2) a wriften 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, certirythatthis project is consistentwith the North CarolinaCoastal Management Program.
River Basin RulesApplicable ToYour Proiect:
E Tar - PamlicoRiver Basin Buffer Rules
I Neuse River Basin Buffer Rules
] oth".,
lf indicated on front of permit, your proiect is subiect 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 (9 I O-796-7215) for more information on how to comply with these buffer rules.
Division of Coastal Management Ofiices
Elizabeth Citv District
401 S. Griffin St.
Ste. 300
Elizabeth City, NC 27909
252-264-3901
Fzx:.252-264-3723
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Washington District
943 Washingon Square Mall
Washin4on, NC 27889
752-946-6481
Fax: [phone]
(Serves: Beaufort, Bertie, Hertford, Hyde,
Tyrrell and Washington Counties)
Wilmingon District
I 27 Cardinal Drive Ext.
Wilmington, NC 28405-3845
910-796-72t5
Fax: [phone]
(Serves: Brunswick, New Hanover,
Onslow - South of New River lnlet-
and Pender Counties)
http://porta.l.ncdenr.orglweb/cm/dcm-home
Revised 7/06/ I 7
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
2s2-808-2808/ r -888-4RCOAST
Fax: [phone]
(Serves: Caneret, Craven, Onslow -
North of New fuver lnlet- and Pamlico
Counties)
EZ Dock Quote
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CERTIFIE DMA IL.RETU RN RECEI REOUE STED
Name of Property Ow
Address of Property:q
(Lot or Street #, Street o Roa d, City & County)
ner:--\\\
Agents Name #:
Agent's phone #:
Mailing Address: _
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i f".t?by -""{ry that I own property adjacent to the above referenced property. The individuarapplying for this permit has descriuLo t6 me "" "nJ*n onit" attacneo oLwingjth" o"r"iijrn.ntthey are proposinn o d*idtoi oroo*,no. *fr iii"it,ir!]*r., o" proro* *r,n,. ,"n"r.
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have no objections to this proposar.
-
I have objections to this proposar.
(Property Owner lnformatlon)iparian Property Ownor lnformafl on)
,s,alure
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Print or Type Name
Rrrsp cr.hqr a El" f] c+
Maling Addess Mailing Addrass
l,\ {"1" {u Aq.ca Vip
Telephone Number / E
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Telephone Number
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mail Address lls\
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DIVIS]ON OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION^^,AIVER FORM
whet ls belng prcposed, ttou must
10 days of receipt of tils no{ce.
Signature
\F\.\\R * q€-\s-\ (\Qy_utosb
Pint or TWe Name
or by cd lng 1-8884RCOAST.
I understand thar a pier, oo.*, ,*nnn'lfiiH:r::iJ'fl rreakwater, boathouse, or rift mustbe set back a minimum distance of td komhy 9r"" oi,i[ari"n access unress waived by me. (rfyou wlsh to waive the setback, you must lnifl;l tne appr6priate blank below.)
I do wish to waive the 15, setback requirement.
I
t I 6t I do not wish to waive the 15, setback requirement.
5
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Date Dote
(Revised Aug. 2014)
COMPLEnE r,is SEC:ION
Dato of
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DWC Nanc. m_4197659806
EZ Docl, Inc
SrE Ealt Higbwry 60
Motrcn, Mil6ood 65108
Phoe: I [phone]
Fa* l1t7) X3t2n2
NOnC? R!.dlZ Dcllimir.d 'rEty.I!ftny. Alot o&d rhhSrr EZ DocI do.r Do. ?[r dEn s€qhilunt.. d.tc! c.l)ld by ui.ddizct lFdiftrlbr of EZ Docl Hrr &d.id u.anffi ra.hlEr dot
EZ D(.* Prodr.t.
General Notas:
l- ,tl. drn{ dG !.h.n c srlsi4, on6.rrEi.d&.MjoA
6.rLi l,lrdl r{!.nfd!ffiir. r-rd !.h drhr.
aeir.( &lEfu mryt &bjLd.
1, Na I N rl.,H wrr,trrd. HrGiU! bErln id6et,
ria.n d.r. r.Grl,9* d ldl h(a&c..a
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FtLlabt l-rdoa c!.ri{ -a -.rlz h4, F!d6 a
l'r rEaqa.o?. ,'d.B U O6tlc-EEDrbrE
'q...6illtFi,r ii.s r & err&, Boladcr.a&.iaior.rct.id- tuorioc.dtdi. d e dEz k
I lclor.c! rz Do.l O*D M&t for.adi.ird.hn!,
Dock Livc Losd of 62.5 ,bs/sqn
Low Profile Docl tjye Load 30 lbtsqlt lffiEN-lI ,,lse I
NC Division of Coastal Management
Cashier's Official Receipt 72032 a, t @o
Oate:7 zoQD/I
Received From:SZbck S),^4n a-r,at^^ , Ztt
Permit No.:4e'b7 8 c
Applicant's Name:y'iek*oo)
$frDO.oa
Check No.:atqT
County:
Proisct Address:
Signature of Agent or Applicant:
Signature of Field Representative:
Date:
Oate:
>C
Please retain receipt tor your records as prool of payment tor permit issued.
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