Dockside Yacht Club Inc. 80416C

AMA / ❑ DREDGE & FILL O 8(4 1 6 A B C D
ENERAL PERMIT Previous permit#
ew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authori ed by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission i q ap area of environ ntal concern pursuant to 15A NCAC
2tWattd.
Applicant Name Project Location: County
Address vvStreet Address/
i State Road/ L t #(s)
City State IP 3 I I i❑
Phone # -Mail Subdivision
Authorized Agent I A,
y 1
ElCW EW PTA
ElES
Affected
AEC(s): ElOEA ElHHF IH
❑ UBA
❑ PW •
ORW: yes / rCi PNA yes /
";
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s)
Floating Platform(s) �..
Finger pier(s)
Groin length •�
number
Bulkhead/ Riprap length f'
--
avg distance offshore
max distance offshore
Basin, channel
—
cubic yards— ----
�y
Boat ramp
Boathou4BIaliftq
Beach BuillddoAzig
Other
Shoreline Length t
SAV: not sure yes no --
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
or Applicant
i RA HMO UPI MMU
El PTS Phone #
Adj. Wtr. Body
Closest Maj. Wtr. :..y rz� t .mil
(Scale:
❑ See note on ack regarding River Basin rules.
r
xw- Ct);4q✓,1/L
PermitOffiter's Printed
read compliance statement on bao <of ermit Signa ure
C eck# 'Ts`suiFngDat'1 Expira ion Date
Application 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, certifythatthis project is consistentwith 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 FO CAMJ� PERMIT APPLICATION
Name of Property Owner Requesting Permit: J)Mk5jje ya(.�t Z�,c
Mailing Address: Skip Siorve4, 311 Axf 4 ✓ems '
Phone Number: Z 5 Z- 2 4 7- Y `B R O -_
Email Address: dOCks itrteXC u�c WF,c%t. Gow+ -
I certify that I have authorized t,.,,afo�%aa. cc.�4 E a- f .L�t
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: 4 os
13,E ILA - l z �.; � ; v, 5L(, I,r
at my property located at Lec4cl { -
in 6a County.
I furthermore certify that / 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
Signature
Print r Typ Name
Title
..lt..
Date
This certifications va r rough

n

ADJACENT RIPARt„AN PROEERTY OWNER STATEMENT
I herebycertify that I own r j �oC �j t N� L4C s
y property adjacent to
(Name of Property Owner)
property located at 3o ( 11 ar-evr 51vft4
(Address, Lot, Block, Rgad, etc.) N C
in (Wate ) (CityrTown dtor County)
V
has described to me, as shown below, the development proposed at the above
1 have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing devafopment must fill rn deserlptifon below or attach a site drawing)
5 0(a- JvckLbk*%Aq& OP pv-vrep�
t7oc p ASP
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.
(5��T� I do not wish to waive the 15' setback requirement.
(Pro Owner Info atlon)
S ire
Phrrt or Type Name
s.'PStove, 3lt Street
0e469 Address
..I's��
city/stafelzip
7r,?_ ?G'x-46C16
Telephone Number/email address
J
Pint or T pE� N
Mg. r g A
fidlely
Ciryf��ip � �v • �� T
i'elephohe ubert enraii address
Date*
(Revised Aug 2014)
"Valid for one calendar year after signature'

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