Vitak, John 80443C

AMA / ir
DGE & FILL (Y0A B(C J D
ENE PERMIT Previous permit # ��
iN eww ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality 1
and the Coastal Resource 0 1mission in an Irea of environ ntal concern pursuant to 15A NCAC a _X I
Rules attac d.
Applicant Name Project Location: County
Addr s 1 Street Address// State Road/ Lot #(s) n—
Ci State ZIPI4AJV
d'�-
Phone # - ail Subdivisi in
1. r
Authorized Agent City ZIP
Affected ElCW EW TA El ES VNIA
Phone #River Basin
AEC(s): ElOEA ElHF ❑ ElUBA Adj. Wtr. Bo at / an unkn
❑ PWS:
ORW:s / no PNA yes / n Closest Maj. Wtr. Body
Type of Project/ Activity
LV(Scale: �� )
Pier (dock) length �—
Fixed Platform(s)
Floating Platform(s)_----
Finger pier(s) __—
Groin length
number "
Bulkhead/ Riprap length �c �—
avg distance offshore
—max distance offshore
cubic yards l
Boat ramp
Boathouse/ Boatlift--
Shoreline Length
SAV: not sure yes o--.._!__................ A....___....----.-._.......... __
......... --..
Moratorium: n/a yes o
i
_-- ----
Photos: yes o
Waiver Attached: yes o
A building permit may be required by:
( Note Local Planning Jurisdiction) �/� � A
Notes/ Special Conditions f,`(Y/ XJVV
�/ It
r
Agent or Appli✓=ant Printed Name
Z
ure Mlease read compliance statement on back of 9- .t**
ff
�)
pplication Fee(s) LhJck# ii
Permit
Issuing
❑ See note n b `k regarding�River Basiry�ules. /
JJ

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 (910-796-72 15) for more information on how to complywith 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
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)
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 FOR LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:d IV�E�T�,✓r�
Phone Number: z s z --
Email Address:
I certify that I have authorized _ -1 04 0- 1 1�0 pO/
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: 0,--
at my property located at - _ f -0 &JX P ?"v A.,19 �e C.1 g,7x, e>r �
in �;L,�r�i �,�T' County.
A /C
I 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.
Property Owner Information:
:1
Si
gnature
vff.cJ rC
Print or Type Name
rifle
4
Date
This certification is valid through I I

�� i

I hereby certify that I own property adjacent to G I/; __ - /� $
Property located at � O 3 A%P(Name-of Owner)
(Addre$s, Lot, Block, Road etc.}
on �F � � �,v[_ ln'per: ('A'T. f TV N.C.
' i
�) (My/Towit and/or Couf fty
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no obpx*on to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
2 S-�lIIx l= 27 U i �
I -understand that a - --v ■ •....w
must f� set back a mini u�m -clock,
istance gs, -boat gyp• breakwater, boathouse, lift, -or groin
me. (If you wish to waivethe� � area of riparian access unless vwaived by
setback, you must-inlSal the-appre-blank below.)
-1-do-wishtowaive the 16-setback -r,equirement.
I do not wish to waive the 9 5' setback requirement.
�iG, 3
Ma11109 Aft ess
QfY
%1
Telephone Number/email &Wrens
_ y.--Z.v - Z_ (
Date
*AIMId f~ wnw wwiww.inr..w^P wiMr wiwnwh.ew*
(AU1aCOMP FI rmation)
f,
ttre
%or le- ,
c� Oar VC-f gS
Number/email address
-21 -Z1
Date* --
(Revised Aug. 2014)

1 hereby certify that I own property adjacent to J.—, fa "-) , Q /Z ,
s
property located at 50 f'T i / (Name of Property Owner)
one ' �- (Address, Lot, Block, Road-, etc.}
/� /L , in __,ai "ram N.C.
��srbodY} �City/Town andfor County} '
The applicant has described to me, as shown below, the development proposed at the above
location.
_Z I have flo objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(I» U"'k olproPmftdbve/op~mtrst W irtdesor4Wwbelow -or aftschasflle-~ne
z�
;3eA7- 3,4S;,(L)
r
%►�- 2 of'
MA41^;'
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 inMai the -appropriate- blank below.)
I-do-wlshto waive -the 1V.setback. requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner tnrarnim )-(A41mew P
r''operty- Owner- Information)
Print or Type Name -- es
ttAd &—c 10
Chy/p z5 -'G
Telephone Number/ email address
Date
_ -9,U - y 4 ?- ? 3P
Telephone Number/email address
Date*
14X.1-164 4„a ^.,...,,,e.,�.,e..a ... _ _4_ _;...,.,s.._* (Revised Aug! 2014)

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