Travis, Donald 78297C

0eAMA / DREDGE &FILL
NE L PERMIT
w ❑Modification ❑Complete Reissue El Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality i I
and the Coastal Resources Commiss• n in area of environmental concern pursuant to 15A NCAC
Applicant N m t Project Location: County
Address Street Ad ress/ State Roar
City State ZIP
Phone # -Mail `-- Subdivision
Authorized Agent City
oa
Affected ❑ CW EW TAd. A ES PTS Phone #
❑ OEA �HHF I ❑ ❑ UBA El
N/A Wt
AECs; r. Bod
�� ❑PW I
ORW: yes / PNA yes / no Closest Maj. Wtr. Body
or Applicant Printed Name
E A B C D
Previous permit #
Date previous permit issued
read compliance statement on
ication Fee(s)

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 1) 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 howto 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/ 1-888ARCOAST 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 CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: ' � � f `� �L
C. -TtqVnJ2.
Mailing Address: B(�(ti'' t1l
n7L dNTZC 13F/ c �f
Phone Number: 0� T 7 7
Email Address: `c(c t( A U
o� I/t f ./YYLcCh c; ►�
I certify that I have authorized u
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: Ru, 1A !L<"',SCfVj-"3 rl )r)
L"4 11 , TU, 1d Pet;, PO
at my property located at 1) -3 '1
County.
1 furthermore certify that 1 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:
Signature
Print or Type Name
Title
Date
This certification is valid through 1
RECEIVED
MAR 0 4 2021
DCM-MHD CITY

..
- �i
,�

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to l )ut-4 2- NL3% « —,VIA
0 k S 's
(Name of Property Owner)
property located at —SA-
(Address, Lot, Block, Road, etc.)
on �s�t�a� , in A- - - , N.C.
(City/Town and/or County)
(Waterbody) (Cit
The applicant has described to me, as shown below, the development proposed at the above
location.
\, I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
1
o
-
o
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 RECEIVED
me. (if you wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
MAR 0 4 2021
40, 1 do not wish to waive the 15' setback requirement. DCM-MHD CITY
(Property Owner Information) (Adjacent Property Owner Information)
Signaturec>v���� `"t�rz.�; 5 Signature* l 1• , °� /
Print or T pe Name P tnt or Type Name
k lam C\AAn oti A( n AL) v IS
1t�a#ing Address �, ` Mating Address
1 �-1 «�:� �c� �c,� ,,� <,L r , ► Kum t>Al
`-/�r(✓�.r;t� c ku city/State/Zip ,�- J � U� �l -7k Itty/ of Lip
Telephone Number/ email address Tel p m one Nuer email address
_ (41 :3C4f r,J
Date Date * 1 "
(Revised Aug. 2014)
"Valid for one calendar year after signature`

ADJACENT RIPARIAN PROPERTY OWNER AT ME T
I hereby certify that I own property adjacent to Name of Property Owner) S
property located at
(Address, Lot, Block, Road, etc.)
on n ,na\ in �r \�a � C:_
N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
,C I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must rill in description below or attach a site drawing)
� w
v
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 waivedA-CE)VED
i )- t'-'F me. (if you wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement. MAR O 4 2021
I do not wish to waive the 15' setback eq nt. ®CIVi-MHD CITY
(Property Owner Information)
PoNa�p •Tr�a�rs
Signature c-,q lA -T�a ui 5
Print or Typ Name
1�iling Address 'C
l� i c-
City/State2ip 5 G�
Telephone Dumber/email address
Date
(Adjacent Property Owner Information)
Signature's Ol �I (n07V
Date*
.2$511.-4
/ email address
Walid for one calendar year after signature*
(Revised Aug. 2014)

A 0
'N'
K
ITA
45-
ADA.).
It
SO vqx�� ni -WrAe MVAj%"j A46 14'k VM. lowo t, vtk
-w -64
lc: ilk -7i
AA It Al

its
({ O um
f !`- N
a
U I i
g2 No
i
a r�
a..+Z.-7-
12
a y'
Wig
Oia
j
a
EX3
} 3@
cq
y � �
�Ua
M �
ti
N 0 Oo W w ~O' R O $mod
as �y+
W °
A ", z Q o
o b b o ai r� E
16
q •, o a � �Q�
O U p N 8 U-6
v
«S a w U A
00 N
Q � E z G1 O �" a n O E
O A W O U C7 N 00 0c O o
Go LO
a b w
E"
ao w
'b 04 6J Cd b
DS FpFi 6l pOq v� iC 3 C. b ,C +, .� y �'
�1 G7 U ~ M ti i M Q' �l a 61 •F"i ES O Rt .-i O �d 6� :; 0) ._ E

t'.0
It,
i
............
SJ
Xt
-
P'
r �
n r.
In
r 1
i
�
1
�k