78046A_Pitts, Donna_20210309

❑LAMA / ❑ DREDGE & FILL N9 78046 {A B C D
GENERAL PERMIT Previous permit #
-]New ❑Modification ❑Complete Reissue El 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 I SA NCAC
❑ Rules attached.
Applicant Name �Oo (1G Ptli5
Address A 39.Z Q,, ie� tad
City �_ 5) CI J(�'6" State ZIP
Phone # (7157) " S I qS E-Mail �=t Lci L,
Authorized Agent Tf c: �. � _) Li l ` l.
Affected ❑ CW NEW [K PTA k] ES N PTS
AEC(s): 0 OEA ❑ HHF ❑ IH ❑ URA ❑ N/A
❑ PWS:
ORW: yes / no PNA yes / 66DO
Type of Project/ Activity
Project Location: County
Street Address/ State Road/ Lot #(s)
t 1('- r,uJ C..,
Subdivision ec- a br-.Q0h
City L) C V1 ' Gn zip
Phone # ( ) River Basin
Adj. Wtr. Body _ (nat /man /unkn)
Closest Maj. Wtr. Body
'�s �■iiiiii�`
Pi I
NEW EVEN MEN IMENE NEMEN MEMO
Elm
M. MEM
MOME
Mon
cubic yards
Boat ramp
Boathouse/ Boatlift
IN mom 11 In in IN ONE ME
Beach Bulldozing
MEN
Other
Shoreline Length
yes no
yes no
A building permit may be required by: 0WO \ 010 f\.4 ❑ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
Signat//ure^^ ** Please read compliance statement on back of permit'`
Application Fee(s) Check #
CtIJ41 C",
PermitOfcer's Printed Name
Signature
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

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to jam, { 5
_ 's
Property located at ame of Property Owner)
� 2
(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 proat the above
location. posed
` I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Indhridua/ proposing development must fill in description below or attach a site drawing)
iceklte
IV
I
WAIVER SECTION
1 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 15' setback requirement.
(Property Owner Information)
(Adjacent Proper Owner Information)
Signature
Si atu e*
Print or Type Name
Pint or Type Name
Mailing Address -% 7 ��� <<� c / ^u,
Ma►l�g �Addre.4
City/Stire/zip /+C Z7g3Z
City/State/Lp
Telephone Number /email address 221- k 777 3 33 - D'71
Telephone Number/email address
Date _ 3-6- -202
Date*
"Valid for one calendar year after signature' (Revised Aug_ 2014)
i

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
, _ ame of Property Owner) s
property located at �, "7 C—� A r � �, 4._, h ��,� :2
on (Address, Lot, Block, R d etc.)
(Waterbody) N.C.in
(City/Town and/or county)
The applicant has described to me, as shown below, the development proposed at the above
location.
! have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(lndMdua/ 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. tjUi r
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjace Pr e
rty�wner ormation)
o
Signature S1 f
*. _
`� try �., /'t /V
Print or Type Name Print or Type Name
Mailing Address
CifY/State/Zip
Telephone Number/email address
Date
*Valid for one calendar year after signature*
`l
i
Mailing Address 10
City/StatelZi� � /
ieftl
( ( 2 7
l
Telephone, Number/ may address
L/ 1 �2
Date #
(Revised Aug_ 2o14)

41- AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit: ,x
Mailing address:
Telephone Number:
I certify that I have authorized M'iL - v; S L /
(agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of I��tl je_k ,,,
at my property located at
This certification is valid through een' e iC � r --/ © j
� �a �� (date).
(Property Owner Information)
Signature
Print or Type Name
Title, co. owner or trustee for property
Date
Telephone Number
Email Address

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