Kilgore, James 79613C

4CAMA / ❑ DREDGE & FILL M 79613 A B D
ENERAL PERMIT Previous permit #
Lr ew ❑Modification ❑Complete Reissue ❑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 a vironmental concern pursuant to 15A NCAC
„dam. � � % Rules ached.
Applicant Name Project Location: County N�R�
Address"2P114 Street Address/ State Road/ Lot #(s)
City tate ZIP l�
Phone # - ail Subdiv�i�
Authorized Agent CityZIP
Affected I� W W PTA
AEC(s): EA HF IH
❑ PWS:
ORW: yes /(R ) PNA yes I
Type of Project/ Activity
Pier (dock) length (e)
Fixed Platform(s)OrN
Floating Platform(s)
Finger pier(s)
Groin length `�—
number
Bulkhead/ Riprap length
avg distance offshore %.._
max distance offshore
Basin, channel
cubic yards
Boat ramp
Boathouse/ atlif t
Beach Bulldozi
Other N"(k
Shoreline Length i
SAV: not sure f no -- -;-
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes o
A building permit may be required by:
(Note Local,. Planning jurisdiction) 1
Notes/ Special Conditions
❑ ES ❑ PTS
❑ UBA ❑ N/A
r C./I I
Agen r Applic
ant rinteded Name
Sig ture * ase read compliance statement on bac f pe mit
Application Fee(s) heck #
Phone # �-
Adj. Wtr. Body
Closest Maj. Wtr. Body
i
I
Printed
Basin rules.
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 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

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �� �n�� T).. � 0! 6t_C_gF 's
(N me of Property ner)
property located at
(tom J r (Address, Lot, Block, TtJec.)ej
on in � • e—, N.C.
(Waterbody) (City/Town and/orCounty)
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 DRAINING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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.)
do wish to waive the 15' setback requirement.
1,7 I do not wish to waive the 15' setback requirement.
(Property Owner In rmation) (Adj ent Property Owner Information)
A�c 1
ature Si tur
Print or Type Name Print or Irype Name
Mailing Address Mail' n Addresa
CitylState/Zip City/State/Zip
Telephone Number Telephone Nu ber
Date Date
(Revised 611812012)

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ADJACENT OWNER STATEMENT AND RECIPROCAL AGREEMENT
/;f'I 41
THIS AGREEMENT is made and entered into this `�,-.- day off; by and
between aA-d4C% Kiir&tQ , (hereinafter called "Requesting Owner")
and (hereinafter referred to as "Adjacent Owner").
WITNESSETH:
THAT WHEREAS, Requester Owner 's tl a owner of certain property located at
Al )G AIC identified as PIN number
County, North Carolina, and
WHEREAS, Adjacent Owner owns property that shares a common boundary with the t
property of Requesting Owner, and
WHEREAS, Requesting Owner has sought a permit to install a pier, dock, mooring
piling, breakwater, boat house, lift or groin within 15 feet of my riparian access, and
WHEREAS, Requesting Owner can only obtain the permit if the Adjaccnt Owner
executes a "Adjacent Riparian Property Owner Statement", and `
WHEREAS, the Requesting Owner has asked the Adjacent Owner to execute such a
statement and the Adjacent Owner has agreed to do so upon condition that this agreement be
executed, and
WHEREAS, the Requesting Owner has agreed to the terms hereof and commits tlic i
Requesting Owner and his, her, or their successors and assigns to the terms hereof:
NOW, THEREFORE, IT IS MUTUALLY AGREED AS FOLLOWS:
i
1) That Adjacent Owner will execute the Adjacent Riparian Property Owner Statement.
2) That the Requesting Owner hereby obligates himself; herself, or themselves, and their
successors and/or assigns to execute for the benefit of the Adjacent Owner an Adjacent Riparian
Property Owner Statement in the event that the Adjacent Owner should, at some time in the
future, request execution of such a statement.
This day of tjugus&,�.
Requesting Owner
Adjacent Owner V Adjacent Owner
s:nvrvxx:sr.,iaa.,R• arum<;�a�a u:�y,�.ryi A�n.,���.w��a

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to _J�4►%�'
(N rneof Property ner)
property located at ,P, o 144'
(� (Address Lot, Block R ad,
on vim€,\ in lti 0 ( c� N.C.
(Waterbody) (City/Town and/or o�)
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)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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 In rmation)
aue
�°t&s
!Tint or Type !Name
MailingAddress
r
City/state/Zip %�----
Z ;2-77z-3 32
Telephone Number
Z? }
Date �
(Adjacent Property.9wner Info
or
Telephone Number
Date
.2.
(Revised 611812012)

ADJACENT OWNER STATEMENT AND RECIPROCAL AGREEMENT
T141S AGREEMENT is made and entered into this '?, day o£.AaPrr , lr9i$; by and
hetween (}} tM6% D, ' t % &0 , (hereinafter called "Requesting Ownee')
ands Z1, 4 .VY -i}4Xb/l/f> !'� ,� yp� d/3i (hereinafter referred to as "Adjacent Owner").
,411�X1�1//Mrr- " r- WI7'NLSSETIi:
THAT WHEREAS, Re?questin Owner 's flip owner of certain property located at
/%A1,44) 'ply A)e- identified as PIN number
County, No—� Carolina, and T
WHEREAS, Adjacent Owner owns property that shares a common houndwy with the
property of Requesting Owner, and
WHEREAS, Requesting Owner has sought a pennit to installa. pier, dock, mooring
piling, breakwater, boat house, lift or groin within IS feet of my riparian access, and
WHEREAS, Requesting Owner can only obtain the permit if the Adjacent Owner
executes a "Adjacent Riparian Property Owner Statemeut", and `
WHEREAS, the Requesting Owner has asked the Adjacent Owner to execute such a
statement and the Adjacent Owner has agreed to do so upon condition that this agreement be
executed, and
WHEREAS, the Requesting Owner has agreed to the tenns hereof and commits the
Requesting Owner and his, her, or their successors and assigns to the terms hereof.
NOW, THEREFORE, IT tS MUTUALLY AGREED AS FOLLOWS:
1) That Adjacent Owner will execute the Adjacent Riparian Property Owner Statement.
2) That the Requesting Owner lierchy nbligates himself, herself, or themselves, and their
successors and/or assigns to execute for the benefit of the Adjacent Owner an Adjacent Riparian
Property Owner Statement in the event that the Adjacent Owner should, at sonic time in the
future, request execution of such a statement.
This _5 day of Auguxi-, .
Reqdesting Ow r j' Requesting Owner
j ecnY.O-tvne>:_--- �- Adjacent Owner
SU&1.9"M

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