78147A_Holloman, William & Mary_20210420

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CAMA / ❑ DREDGE & FILL N9 78147 B C D
GENERAL PERMIT Previous permit#
QNew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality i i i �� 1
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
® Rules attached.
Applicant Name W 1 1 k, c. m
Address i) U i11hP tag�
City State FJC ZIP 7 i �-
Phone # 2-1 tI j S5 E-Mail
Authorized Agent T Y a„ ,--, L, j k
Affected ❑ CW i[I EW W PTA ❑ ES ElPTS
AEC(s):
ElOEA ❑ HHF ❑ IH ❑ URA ❑ N/A
❑ PWS:
ORW: yes / no PNA yes / no
Project Location: County�" � :'' JQ
Street Address/ State Road/ Lot #(s) L o} # V1
Ck Cb C. T
Subdivision )CY-, l poA R_ Pe0 61
City (r P Y\ zip IR 3-L
Phone # River Basin h .> Q r
Adj. Wtr. Body n Kc)(j.)G r\ t ve;Y (at Iman /unkn)
Closest Maj. Wtr. Body �� YhL LP Sal,J
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Agent or Applicant Printed Name
/� i%
Signature ** Please agcompliapce statement on back of permit
Application Fee(s) Check #
��h � � � c�ti ►�fiYpe
Permit i r s Printed Name
Signature
y �Z�17 � 3/2a�zf
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 (910-796-7215) 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/ 1-888-4RCOAST 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

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit: Till
Mailing address: I I H lA I ; r\
Telephone Number: 7 Sj P,7y _ 1 C1
I certify that I have authorized `Tr�.�, (_; `�
(agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of i ,og s GUC
at my property located at
This certification is valid through o �
V (date).
(Property Owner Information)
Signature
Print or Type Name
Title, co. owner or trustee for property
y- 9 ,
Date
Telephone Number
Email Address

ADJACENT RIPARIAN PROPERTY OWNER STATEIIAENT
1 hereby certify that I own property adjacent to _ / C' Oki
H .
'"i v`^ S
property located at 1 l 4 LA.3 , ,�u(Name f property Owner)
(Address, Lot, Block, Road, etc.)
(Waterbody) in , N.C.
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locat'n.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fi/I in description below or attach a site drawing)
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 waived by
unless
me` (If you wish to waive the setback, you must initial the appropriate blank below_)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
d'acent Prope Owner Information)
Stgnvrl'L
LCGri �ie� ature*
Print or Type
�/ c/ � , - 11 — Print or Type Name
Mail► ddre \ lb 1,74-
_G 0/1C 2oZ _ (ley Address
�
City/State/Zip F�
7 7_ 7 cf_ 1 C! City/State/Zip
Te%phone Numberfemail address 1913z--
Telephone Number/email address
Date — %40 a) izy,)V9
Dale`
'Valid for one calendar year after signature' (Revised Aug_ 2014)

AD./ACENT RIPARIAN PROPERTY OWNER STATE ENT
1 hereby certify that I own property adjacent to 11 �1` 6"M-14l�
(Na s
property located at /� L,/I` n i1.p 6 c c of Pro x g RertY O caner)
on ���-p CAI (Address,
q , in
(Waterbody)
The applicant has described to me, as shown below,
location.
T_ I have no objection to this proposal.
I have objections to this proposal.
ck, Road, etc)
(City/Town
county;
N.C.
the development proposed at the
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
`lnc►ividual proposing development must fill in description below or attach a site drawing)
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 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 1 5' setback requirement.
(ProPy e/r Information) (Adjacent Prope Own Information
Signet re
/� Grp �� Signature
Pent ar Type Name
6� .-tic
or Type
n Name
Matltn Ad#ress
!-"1�,1 Matilling A�-.�t�J CitylState/Lp z
7 S7- 7t/— Jf/ c�rj 56;/State/Zi
Te%phone Numberl error W 7 �d Z
Telephone /y ail address
Date
Date:,
"Valid for one calendar year after signature- (Revised Aug 2014)
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Legend
114 Winnebago Trail
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