Boucher, Gerald 79568C

AMA / ❑ DREDGE & FILL
NERAL PERMIT
New ❑Modification El Complete Reissue El Partial Reissue
9 79568
Previous permit #
Date previous permit
/issued
As authorized by the State of North Carolina, Department of Environmental Quality -Z
and the Coastal Resources Commiss. iryan ar of environ ental concern pursuant to 15A NCAC
r /' �V__
Rless attached.
Applicant Name C er 0 u c � y Project Location: County (
B (C) D
Address l 1 �(J(`� , ( / Street Addres�s/jSttate Ro(a� Lot #(s)
City e State NL ZIP / l L1_ ✓��
Phone # E- ail Subdivision
Authorized Agent �,� e�� City el ZIP
Affected ��/ice' A ❑ ES ❑ PTS Phone # ( _) River. Basin
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body 1 a man unkn
❑ PWS: ! .i
UIA
a
Agent or Applicant Printed Name
Sig r Please read compliance statement on back of permit
�; r i ►3�c
IppDocationFee(s) Check#
RUB 14 D&~ pad
Permit Offi er's Printed Name
Signature
Issuing Date Expiration 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

AGENTAL Q, JOW ATION MR CAMA
Name Of Property Owner Requesting Permit:
—(5U—C— -k-
Mailing Address:
3
Phone Number: 6 -7
Email Address:
I certify that I have authorized 4
g7p
Agent Contractor V
to act On mY behalf, for the purpose of applying for and obtaining all LAMA permits
necessary for the following proposed. development:,,
4
ead
at my property located at
in CA County.
1 futtherrf79re ce'W, that tam auftfized tO.grant..and do in fa
ct grant permission t©
Division Of Coastal Management staff, the Local Permit Officer and their agents to enter
on the af0rementioned lands in connection with evalu
permit application. afing information related to this
Property Owner Information:
u,u_j c e-
L
Date
This certification Is valid through

ADJACENT Ejea M PROPERTY OWNER STATEMENT
1
l hereby early that 1 own property adjacenito G, erc t t�h= '
S
(Name OMPerfy owner)
property located at `ft 1�j Sh 0e PS t Q e- GEC' % V G
(Adders, Lot Block, Road, etc.
on whi'�G CGt k '; . in Swong,QY:Q VA N.C.
(Wderbody) ! {dawn anchor County?
The applicant has described to me, 1 s shown below, the development proposed at the above
location.
I have no objection to this proposal.
i
I have objections to this pmposai.
i understand that a pier, dads, mom, r ; br+ "atm. boathouse, IK or groin
must be set back a minimum dim 'tit rr► s of acoOss untass waived by
me. (If you wish t4 waive the _ Est * below.)
Dam
I do wish to waive the 1 `- tads requirement
i do not wish to waive tfie 16 setback requirement.
Infbanafta)
►n)
(Revised Aug 2014)
*Valid for one calendar year afba Isignatum-

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
i
i hereby certify that i own property adjacentto Cz era t Ro�Aahelt is
Name of'Property Owner)
property located at L A Sh a r 6S 1 el e dr1 V e
(Address, Lot, Block, Road, atc'
on W h�at`C 00. k I in 5y ftSb in r C) / t e r N.C.
(Waterbody) j (CiW17own and/or County)
ap licant has described to me, as shown below, the development proposed at the above
to I
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION ANWOR DRAAgNG OF PROPOSED DEVELOPMENT
(Individuat 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 se back a minimum distance of 16 from my area of riparian access unless waived by
me. (I wish to waive the setback; you merit initlat the appropriate blank below.)
I do It
h o waive the 15'. setback requirement.d°a sh to ive the 15' setback requirement.
(Property Owner Information) (A j ent P ropp
erty Owner Information)
Michc%el ar H=4 'T®1Slr,
Print or a Name Print or Type Name
2SM-tte, Lirtcl-v�ra�d
Mailing Address Mafing Address
sy-oms$ Swan sbot0 Hf 22iS S4
CitylStatelZip ., CFty/Siafel.Zip
Telephone Number/email address
Date
Telephone Numberlemar7 address
Date's
(Revised Aug. 2014)
'Valid for one calendar year aftersignature*

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
O �
1 hereby cer* that 1 own property adjacent to Name ofProperh► Owner}
Property located at
on
(Waterbody)
as, Lot, Block, Road, etc.
in er 7 N.C.
pty/Town andlor County)
The applicant has described to me, I s shown below, the development proposed at the above
location.
i have no objection to this proposal_
I have objections to this proposal.
DESCRIPT10N ANDIOR DRAWNG OF PROPOSED DEVELOPMENT
((ndividaaal proposing development must fill in description below or attach a site drawing)
i
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, r'rft, or groin
must be set back a minimum distance of 16 from my area of riparian access unless waived by
me. (if you wish to waive the setback; you must Initiatthe appropriate blank below.)
r 1 do wish to waive the 15' setback requirement,
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
ga7�CJ 4ZI
sign� �.c � SQ . Q± chfo r
Print or Typ'4,kamel Pmrt or Type Name
51nor dY PO box 10 Nam_
Mailing Address Maftg Address
� ,swchnisba o�NG, 2969%4
City/State.alp Ciyl temp
2• b
Telephone Wnberlemall adahtps Telephone Number/email address
Date Dae*
(Revised Aug. 2014)
"Valid for one calendar year after; signature*

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