Bransfield HOA 78277C

❑CAMA / ❑ DREDGE & FILL N9 782 % A B D
r. GENERAL PERMIT Previous permit #
El New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previo s peermit' d
As authorized by the State of North Carolina, Department'of Environmental Quality II
and the Coastal Re ources Commission in an a env me I concern pursuant to 15A NCAC
ules attached.
Applicant Name Project Location: County
Address _ Street Address/ State Road/ Lot (s)
City State ZIP i c i no..rA
Phone # -Mail Subdivision
Authorized Agent City ZIP
Affected ElCW ElEW ElA ES ElPTS Phone # ( \ p River Basin
AEC(s): ❑ OEA ❑ HHF ❑ IH UBA ❑ N/A Adj. Wtr. Body i a /unkn)
❑ PW ,
ORW: yes / PNA yes / o\ Closest Maj. Wtr. Body /f A�
Type of Project/ Activity
Pier (dock) length " �—
Fixed Platform(s)
Floating Platform(s`r-�
Finger pier(s)-.
Groin length "—
t BuBuUdacl iprap length
avg distance offshore
max distance offshore
Basin, channel
cubic yards------_-'
Boat ramp
Boathouse/ Boatlift �
Beach Bulldozing —
Other
Shoreline Length I—
SAV: not sure yes no
Moratorium: n/a yes no
Photos: yes o
Waiver Attached: yes no
A building permit may be required by:
( Note Local Planning jurisdiction)''
Notes/ Special Cgndi�ions � �.1
or ADDlicant Printed
Permit
/lh.
note on back regarding River Basin rules.
q
ure se read compliance statement on b k fation Feels)4 Chec 4
re i_ i —

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 how to complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888ARCOAST
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)
Washington District
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Fax: [phone]
(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
I hereby certify that I own property adjacent to LAm,1 Ld-4-- 's
(Na a of Property Owner)
property located at
(A dress, L , Block, Road etc.)
on , in .�� , N.C.
(Waterbody) (City/Town and/or Coun )
The applicant has described to me, as shown below, the development proposed at the above
locatio
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, 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.)
1% I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property, �br Information)
Si natu e // ,, Si ature* —
Pnn or pe =0 P/rint or Type Name ,7
Ma 1, A0r Ma(ling Admire, s _
60
City/s a Zip City/State/Zip
Tele hone Nu rq1w /email address Teleph ne umber / email address
Date Date
(Revised Aug. 2014)
'Valid for one calendar year after signature"

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
of
property located at
(Address, LKBlock ,Road, etch
on , in L 4,,v`TT i- n/ � � , N.C.
(Wa erbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
c/' 1 have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must flit 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.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
I J ( // C �)j &' .. -
SigrIatre
Print or Type Name
•.
M ilin Addej(s�s���
, VVf/:
City/State/Zip
e,
Telephone Number / email address
Date �y
Information)
Print or Tyge N me '
Mailing Address
City/Stat Zip
'�v ;25:2-G4� -39.2
Telephone Number / email address
Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature*

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