TB_19-01_ Ebert

Issued by WiRO TB19.01
Topsail Beach Permit Number
CAMA
MINOR DEVELOPMENT
t^
PERMIT
NORTH CAROLINA
Environmental Quality
as authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission for development in an area of environment
concern pursuant to Section 113A-118 of the General Statutes, "Coastal Area
Management"
Issued to Gale Ebert authorizing development in the Estuarine Shoreline (AEC) at 122 Boryk Avenue, in Topsail
Beach, Pender County as requested in the permittee's application, dated December 3, 2018, and received by DCM on
January 29, 2019. This permit, issued on February 13, 2019, is subject to compliance with the application and drawing
dated and received by DCM on January 29, 2019 (where consistent with the permit), all applicable regulations and
special conditions and notes set forth below. Any violation of these terms may subject the permittee to a fine,
imprisonment or civil action, or may cause the permit to be null and void.
This permit authorizes: Proposed residential dwelling with deck and driveway/parking area.
(1) All proposed development and associated construction must be done in accordance with the permitted site drawing dated
received by DCM on January 29, 2019.
(2) Any change or changes in the plans for development, construction, and/or land use activities will require re-evaluation and
modification of this permit.
(3) A copy of this permit shall be posted or available on site throughout the construction process. Contact this office at(910)
766-7221 for a final inspection at completion of work.
(Additional Permit Conditions on Page 2)
RECEIVED
APR 172019
DCM WILMINGTON, NC
This permit action may be appealed by the permittee or other qualified persons
within twenty (20) days of the issuing date. This permit must be on the project
site and accessible to the permit officer when the project is inspected for Jason Dail
compliance. Any maintenance work or project modification not covered under MA LOCAL PERMIT OFFICIAL
this permit,require further written permit approval.All work must cease when this
permit expires on: 127 Cardinal Drive Extension
Wilmington, N 28405- 45
December 31,2022
In issuing this permit it is agreed that this project is consistent with the local Land b(
Use Plan and all applicable ordinances. This permit may not be transferred to
another party without the written approval of the Division of Coastal PERMITTEE
Management.

Name: Gale Ebert
Minor Permit#TB19.01
Date: February 13, 2019
Page 2 of 3
(4) All unconsolidated material resulting from associated grading and landscaping shall be retained on site by effective
sedimentation and erosion control measures. Disturbed areas shall be vegetated and stabilized (planted and
mulched)within 14 days of construction completion.
(5) Any proposed for grading within the 30' Coastal Shoreline buffer (as measured from the Normal High Water level)
must be contoured to prevent additional stormwater runoff to the adjacent marsh and/or canal. This area shall be
immediately vegetated and stabilized and must remain in a vegetated state.
(6) All development shall be located at least 30' landward of the normal/mean high water line. No impervious
coverage/built upon area, including but not limited to the house (including eaves), foundation pad, covered
decking, etc. shall extend into the 30-foot coastal shoreline buffer.
(7) This permit does not authorize the excavation or filling of any wetlands, even temporarily.
(8) Shall the plan of development exceed 30% impervious coverage within 75' of the normal high water line, the
applicant shall effectively demonstrate, through innovative construction and design that the amount of impervious
surfaces exceeding 30% impervious coverage within the 75' Coastal Shoreline AEC shall be managed and the AEC
protected. All proposed development and associated construction must be done in accordance with a credible
innovative design plan,sealed and sealed by a professional engineer.
(9) Upon completion of construction and prior to the issuance of a Certificate of Occupancy(CO), a letter of certification
must be received from the designer of the innovative system installed, certifying that the permitted system has been
installed in accordance with this permit, the approved plans and his design specifications. Any deviations from the
approved plans and specifications must be noted on the Certification and a permit modification may be required
prior to receiving a CO.
(10)All structures shall comply with the NC Building Code, including the Coastal and Flood Plain Construction Standards
of the N. C. Building Code, and the Local Flood Damage Prevention Ordinance as required by the National Flood
Insurance Program. If any provisions of the building code or a flood damage prevention ordinance are inconsistent
with any of the following AEC standards, the more restrictive provision shall control.
(11)Pursuant to 15A NCAC, Subchapter 7J.0406(b), this permit may not be assigned, transferred, sold or otherwise
disposed of to a third-party.
SIGNATURE: DATE: k 3 ' 2/'20l/
PERMITTEE
RECEIVED
APR 1'7 2019

7(f)
Locality Permit13 mber
Ocean Hazard Estuarine Shoreline ORW Shoreline Public Trust Shoreline Other
(For official use only)
GENERAL INFORMATION
LAND OWNER
Name er-OLle Et c,--�-
Address S D Co Hawks 7(A,.c y L-r' •
City ?-0-1 e tg G. State ist C. Zip 276 O(,Phone
Email ebr4- alee3v-ync..t\ , CCU
AUTHORIZED AGENT
Name Va.v\4 Li �`t're,i? v,e
Address t,70 3 cO I Ut . l3(vct
City cesnA( Ejeckci, State N C Zip 04/4 Phone "i (p io - 72.O
Email r-av-,cl,,y� 95 bu.:( Q,r 4C. • cow-)
LOCATION OF PROJECT: (Address, street name and/or directions to site. If not oceanfront,what is the name of the
adjacent waterbody.) 122 it errc.{ 12v P 1 De t-t 1 S 01.A.NAa Cconcx(
DESCRIPTION OF PROJECT: (List all proposed construction and land disturbance.)[Derirvo Et;54w'.c $e
5 7I cUv.s-VnAci- �.Le S.V• Hem€
SIZE OF LOT/PARCEL: 5 i) square feet . j 2, acres
PROPOSED USE: Residential [r (Single-family [{i]'Multi-family ) Commercial/Industrial El Other ❑
COMPLETE EITHER(1)OR(2)BELOW(Contact your Local Permit Officer if you are not sure which AEC applies
to your property):
(1) OCEAN HAZARD AECs: TOTAL FLOOR AREA OF PROPOSED STRUCTURE: square feet(includes
air conditioned living space,parking elevated above ground level,non-conditioned space elevated above ground level but
excluding non-load-bearing attic space)
(2) COASTAL SHORELINE AECs: SIZE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR BUILT
UPON SURFACES: id?7 gsquare feet(includes the area of the roof/drip line of all buildings, driveways, covered decks,
concrete or masonry patios,etc. that are within the applicable AEC.Attach your calculations with the project drawing.)
STATE STORMWATER MANAGEMENT PERMIT: Is the project located in an area subject to a State Stormwater
Management Permit issued by the NC Division of Water Quality?
YES NO
REyiIf yes, list the total built upon area/impervio R t our lot or parcel: 1 square feet.
��Vtt��ii I� N, NC
JAN 2 9 29i9

APPLICATION FOR
T4!
re) LAMA MINOR
DEVELOPMENT
PERMIT
In 1974,the North Carolina General Assembly passed the Coastal Area Management Act
(CAMA) and set the stage for guiding development in fragile and productive areas that
border the state's sounds and oceanfront.Along with requiring special care by those who
build and develop,the General Assembly directed the Coastal Resources Commission
(CRC)to implement clear regulations that minimize the burden on the applicant.
This application for a minor development permit under CAMA is part of the
Commission's effort to meet the spirit and intent of the General Assembly. It has been
designed to be straightforward and require no more time or effort than necessary from
the applicant. Please go over this folder with the Local Permit Officer(LPO)for the
locality in which you plan to build to be certain that you understand what information he 0
or she needs before you apply.
Under CAMA regulations,the minor permit is to be issued within 25 days once a
complete application is in hand. Often less time is needed if the project is simple.The
process generally takes about 18 days.You can speed the approval process by making
certain that your application is complete and signed,that your drawing meets the
specifications given inside and that your application fee is attached.
Other permits are sometimes required for development in the coastal area.While these
are not CAMA-related,we urge you to check with the Local Permit Officer to determine ^�
which of these you may need.A list is included on page two of this folder.
We appreciate your cooperation with the North Carolina Coastal Management Program
and your willingness to build in a way that protects the resources of our beautiful and
productive coast.
Coastal Resources Commission
Division of Coastal Management
>
n
Cr
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OTHER PERMITS MAY BE REQUIRED: The activity you are planning may require permits other than the CAMA
minor development permit,including,but not limited to: Drinking Water Well, Septic Tank(or other sanitary waste
treatment system),Building,Electrical,Plumbing,Heating and Air Conditioning,Insulation and Energy Conservation,FIA
Certification, Sand Dune, Sediment Control, Subdivision Approval,Mobile Home Park Approval,Highway Connection,and
others. Check with your Local Permit Officer for more information.
STATEMENT OF OWNERSHIP:
I,the undersigned,an applicant for a CAMA minor development permit,being either the owner of property in an AEC or a
person authorized to act as an agent for purposes of applying for a CAMA minor development permit,certify that the person
listed as landowner on this application has a significant interest in the real property described therein.This interest can be
described as: (check one)
an owner or record title,Title is vested in -rnl>: Fbe-4- ,see Deed Book leireq (0
page artitt in the a, ie,, County Registry of Deeds.
24, 25"
an owner by virtue of inheritance.Applicant is an heir to the estate of •
,
probate was in County.
if other interest,such as written contract or lease,explain below or use a separate sheet&attach to this application.
NOTIFICATION OF ADJACENT PROPERTY OWNERS:
I furthermore certify that the following persons are owners of properties adjoining this property. I affirm that I have given
ACTUAL NOTICE to each of them concerning my intent to develop this property and to apply for a CAMA permit.
(Name) (Address)
(1) 154-tp. m wl r- Ca 10 e 12 o tgit„ry tq ye. 162 L3Jia rPl'e la pr. Apex 'N C 75o`2_
(2) Jerry 1 0 0►e,e C 1 '2 Lf ear`1 k 3v e. 'fib 3Nc .z e li ?lenstn-E-creidc c1e,"., Bel C, 2 7:�13
(3)
(4)
ACKNOWLEDGEMENTS:
I,the undersigned,acknowledge that the land owner is aware that the proposed development is planned for an area which
may be susceptible to erosion and/or flooding. I acknowledge that the Local Permit Officer has explained to me the particu-
lar hazard problems associated with this lot.This explanation was accompanied by recommendations concerning stabiliza-
tion and floodproofing techniques.
I furthermore certify that I 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.
This the 3 day of Der ,20 l pj
Lando er or pe on authorized to act as his/her agent for purpose of filing a CAMA permit application
This application includes:general information (this form), a site drawing as described on the back of this application, the
ownership statement, the Ocean Hazard AEC Notice where necessary, a check for$100.00 made payable to the locality, and
any information as may be provided orally by the applicant. The details of the application as described by these sources are
incorporated without reference in any permit which may be issued. Deviation from these details will constitute a violation of
any permit.Any person developing in an AEC without permit is subject to civil, criminal and administrative action.

SITE DRAWING/APPLICATION CHECKLIST
Please make sure your site drawing includes the following information required for a CAMA minor development permit.
The Local Permit Officer will help you,if requested.
PHYSICAL DIMENSIONS
Label roads
Label highways right-of-ways
Label local setback lines
7 Label any and all structures and driveways currently existing on property
/ Label adjacent waterbody
PHYSICAL CHARACTERISTICS
Draw and label normal high water line(contact LPO for assistance)
✓ Draw location of on-site wastewater system
If you will be working in the ocean hazard area:
Draw and label dune ridges(include spot elevations)
Draw and label toe of dunes
Identify and locate first line of stable vegetation(contact LPO for assistance)
Draw and label erosion setback line(contact LPO for assistance)
Draw and label topographical features(optional)
If you will be working in a coastal shoreline area:
v Show the roof overhang as a dotted line around the structure
Draw and label landward limit of AEC
Draw and label all wetland lines(contact LPO for assistance)
✓ Draw and label the 30-foot buffer line
DEVELOPMENT PLANS
✓ Draw and label all proposed structures
✓ Draw and label areas that will be disturbed and/or landscaped
Note size of piling and depth to be placed in ground
Draw and label all areas to be paved or graveled
✓ Show all areas to be disturbed
Show landscaping
NOTE TO APPLICANT
Have you:
• completed all blanks and/or indicated if not applicable?
• notified and listed adjacent property owners?
• included your site drawing?
• signed and dated the application?
• enclosed the$100.00 fee?
• completed an AEC Hazard Notice,if necessary?(Must be signed by the property owner)
FOR STAFF USE
Site Notice Posted Final Inspection Fee Received
Site Inspections
ym

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: &o- e Eb
Mailing Address: S 20 fo Oa.,,tr ,,J,.rY
I�igt• , C'l Z no o6,
Phone Number:
Email Address: e e -I y! Gegvna;1 , e o rv)
I certify that I have authorized 26 nel (-1-,eC' )� / (7 &__ r s_rinr,
Agent/Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: i>'rr1a OC• e i e4i-3
Pc>L44& rid Can iPw .S �. t-(orrie
at my property located at I Z Z aat-yK Ave . l o f&ct.c( Reac A,
in P .v County.
I furthermore certify that I 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
GA_Le tisevi.f
Print or Type Name
Title
IZ IZ ? l ZUlg
Date RECEIVED
DCM WILMINGTON, NC
This certification'Mand through / /

ROY COOPER
Governor
rMICHAEL S. REGAN
Secretary
NORTH CAROLINA BRAXTON DAVIS
Environmental Quality Director
February 14,2019
Gale Ebert
5206 Hawksbury Lane
Raleigh, NC 27606
Dear Gale,
Attached is CAMA Minor Development Permit TB 19-01 for work to be done at 122 Boryk Avenue, in
Topsail Beach, Pender County. An electronic copy has been sent to the Topsail Beach Inspections
Department and your agent.
To validate this permit, please sign both copies as indicated for our records. Retain the orange copy for
your files, and of receipt in the enclosed,self-addressed
envelope
This is not a valid permit until it is signed and returned to our office.
Thank you for your prompt attention to this matter.
Sin '-rely,
Am. K. P t a
it Sup..rt Technician
N.C. Division of Coastal Management
Enclosures
Cc:WiRO files
TB Inspection Dept.
R. Greene-Agent
State of North Carolina I Environmental Quality Coastal Management
127 Cardinal Drive Ext.,Wilmington,NC 28405
919796 7215

Receipts for
Certified Mail
(Staple Here)
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Date
J 4s-eel W —roe rvi es
A1d'acentroperty Owner
F'o go)L L.g 4
cling Address
V1 en►ca,ssr+ C rde r. Ate_ 273t
City,State,Zip Code
Dear Adjacent Property:
This letter is to inform you that I, FT a Lc E bee have applied for a CAMA Minor
Property Owner
Permit on my property at l2-`2- Spttik Ave. 1op'ctii Beach ,inPNION
Property Address
County. As required by CAMA regulations,I have enclosed a copy of my permit application and project
drawing(s)as notification of my proposed project.No action is required from you or you may sign and return
the enclosed no objection form. If you have any questions or comments about my proposed project,please
contact me at 6119 — fo D 9 — 0 t(9 i-f- ,or by mail at the address listed below. If you wish to
Applicant's Telephone
file written comments or objections with the Topsail Beach CAMA Minor Permit Officer,you may submit
them to:
Jason Dail,Field Representative
Local Permit Officer for Topsail Beach
NC DENR Div of Coastal Management
127 Cardinal Drive Extension
Wilmington,NC 20405
910-796-7221
Since d
Property Owner
O(o Haw sbwcvt LN.
Mailing Address
DO p ode I V NC 27&o�
City,State,
JAN 2 9 2019

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electronic version.For a hardcopy return receipt,
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!C Fnnn n tflfl_An,ll 981c'Panama)PCN 75.111(121NN1-Q(ld7

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Receipts for
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(Staple Here)
l2- 3 — I/3
Date
Brrau- C Abe
Adjacent Property Owner
152 Bria.IrF•e(d D('.
Mailing Address
, >Ic 27S p5-
City,State,Zip Code
Dear Adjacent Property:
This letter is to inform you that I, (To.1e to er+ have applied for a CAMA Minor
Property Owner
Permit on my property at 1 22 gQly It Ave • ►desa.i ,in PN ION
Property Address
County. As required by CAMA regulations,I have enclosed a copy of my permit application and project
drawing(s)as notification of my proposed project. No action is required from you or you may sign and return
the enclosed no objection form. If you have any questions or comments about my proposed project, please
contact me at q I cl - O I fc(+ ,or by mail at the address listed below. If you wish to
Applicant's Telephone
file written comments or objections with the Topsail Beach CAMA Minor Permit Officer,you may submit
them to:
Jason Dail,Field Representative
Local Permit Officer for Topsail Beach
NC DENR Div of Coastal Management
127 Cardinal Drive Extension
Wilmington, NC 20405
910-796-7221
Since ,
Property Owner
oCM S2oc Naw1sbt4s L t.\. ►N/tMF��
Mailing Address N�TON �G
Pal e cOln , d\l� 27r0o(o 92019
City,State,Zip Code
NG

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1 Domestic Mail Only
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irernnea man service proviaes me ronowmg oeneTuls:
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delivery. USPS®-postmarked Certified Mail receipt to the
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signature)that Is retained by the Postal Service— -Restricted delivery service,which provides
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to the addressee's authorized agent.
mportant Reminders: -Adult signature service,which requires the
You may purchase Certified Mail service with signee to beat least 21 years of age(not
First-Class Mail®,First-Class Package Service•, available at retail).
or Priority Mail'service. -Adult signature restricted delivery service,whict
I Certified Mall service is not available for requires the signee to be at least 21 years of ag
international mail. and provides delivery to the addressee specified
r Insurance coverage is notavailabie for purchase by name,or to the addressee's authorized agent
with Certified Mail service.However,the purchase (not available at retail).
of Certified Mail service does not change the •To ensure that your Certified Mat receipt is
insurance coverage automatically included with accepted as legal proof of mailing,it should bear a
certain Priority Mat items. USPS postmark.If you would like a postmark on
r For an additional fee,and with a proper this Certified Mail receipt,please present your
endorsement on the mailpiece,you may request Certified Mail item at a Post Office'"for
the following services: postmarking.If you don't need a postmark on this
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of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply
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electronic version.For a hardcopy return receipt,
complete PS Form 3811,Domestic Return
Receipt;attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records.

U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency OMB No. 1660-0008
National Flood Insurance Program Expiration Date: November 30,2018
ELEVATION CERTIFICATE
Important: Follow the instructions on pages 1-9.
Copy all pages of this Elevation Certificate and all attachments for(1)community official, (2)insurance agent/company, and (3)building owner.
SECTION A—PROPERTY INFORMATION FOR INSURANCE COMPANY USE
Al. Building Owner's Name Policy Number:
Gale W. Ebert and wife Joan E. Ebert
A2. Building Street Address(including Apt., Unit, Suite,and/or Bldg. No.)or P.O. Route and
Box No. Company NAIL Number
122 Boryk Avenue
City State ZIP Code
Topsail Beach North Carolina 28445
• A3. Property Description(Lot and Block Numbers,Tax Parcel Number, Legal Description, etc.)
Lot 28 Block 49 MB 10 Pg 24,25 New Topsail Beach
A4. Building Use(e.g., Residential, Non-Residential,Addition,Accessory, etc.) Residential
A5. Latitude/Longitude: Lat.34-21-07.15" Long.-77-38-54.41" Horizontal Datum: ❑ NAD 1927 ❑x NAD 1983
A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance.
A7. Building Diagram Number 6
A8. For a building with a crawlspace or enclosure(s):
a) Square footage of crawlspace or enclosure(s) 624 sq ft
b) Number of permanent flood openings in the crawlspace or enclosure(s)within 1.0 foot above adjacent grade 4
c) Total net area of flood openings in A8.b 800 sq in
d) Engineered flood openings? ❑x Yes ❑ No
A9. For a building with an attached garage:
a) Square footage of attached garage 0 sq ft
•
b) Number of permanent flood openings in the attached garage within 1.0 foot above adjacent grade 0
c) Total net area of flood openings in A9.b 0 sq in
d) Engineered flood openings? ❑Yes ❑x No
SECTION B—FLOOD INSURANCE RATE MAP(FIRM) INFORMATION
B1. NFIP Community Name&Community Number B2. County Name B3. State
Topsail Beach 370187 Pender North Carolina
B4. Map/Panel B5.Suffix B6. FIRM Index B7. FIRM Panel B8. Flood Zone(s) B9. Base Flood Elevation(s)
Number Date Effective/ (Zone AO, use Base
Revised Date Flood Depth)
3720420200 J 02/16/2007 02/16/2007 AE 11'
FECEIVED
B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood de th enter i
FIS Profile x FIRM ,� `� NC
❑ ❑ ❑ Community Determined ❑ Other/Source: q 'A
B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 ❑x NAVQ 19882 Li`Ot Other/Source:
B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑Yes ❑x No
•
Designation Date: ❑ CBRS OPA

ELEVATION CERTIFICATE OMB No. 1660-0008
Expiration Date: November 30,2018
IMPORTANT: In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE
Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Box No. Policy Number:
122 Boryk Avenue
City State ZIP Code Company NAIC Number
Topsail Beach North Carolina 28445
SECTION C—BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: ❑x Construction Drawings* ❑ Building Under Construction* 0 Finished Construction
*A new Elevation Certificate will be required when construction of the building is complete.
C2. Elevations—Zones A1—A30,AE,AH,A(with BFE),VE,V1—V30,V(with BFE),AR,AR/A, AR/AE,AR/A1—A30,AR/AH,AR/AO.
Complete Items C2.a—h below according to the building diagram specified in Item A7. In Puerto Rico only, enter meters.
Benchmark Utilized: NCGS"BORYK" Vertical Datum:NAVD 88
Indicate elevation datum used for the elevations in items a)through h)below.
❑ NGVD 1929 ❑x NAVD 1988 0 Other/Source:
Datum used for building elevations must be the same as that used for the BFE.
Check the measurement used.
a) Top of bottom floor(including basement, crawlspace, or enclosure floor) 5. 8 ❑x feet ❑ meters
b) Top of the next higher floor 17 0 ❑x feet ❑ meters
c) Bottom of the lowest horizontal structural member(V Zones only) N/A. ❑x feet ❑meters
d) Attached garage(top of slab) N/A. ❑x feet ❑ meters
e) Lowest elevation of machinery or equipment servicing the building 14, 0 ❑x feet ❑ meters
(Describe type of equipment and location in Comments)
f) Lowest adjacent(finished)grade next to building(LAG) 4. 7 ❑x feet ❑ meters
g) Highest adjacent(finished)grade next to building(HAG) 5, 3 ❑x feet ❑ meters
h) Lowest adjacent grade at lowest elevation of deck or stairs, including 5. 3 ❑x feet ❑ meters
structural support
SECTION D—SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
This certification is to be signed and sealed by a land surveyor,engineer, or architect authorized by law to certify elevation information.
l certify that the information on this Certificate represents my best efforts to interpret the data available. l understand that any false
statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.
Were latitude and longitude in Section A provided by a licensed land surveyor? 0 Yes 0 No ❑Check here if attachments.
Certifier's Name License Number
Gairy Canady L-2904
Title :`,,,, C.I�if./�/
NC Professional Land Surveyor .z.:'• ,k': ^ ^ . ., 0�!`
Company Name --- ' �%
^' (t c,
`
Gairy Canady Surveying .
Address a e - :‹C:';;::: =2780 Kinston Highway &1's�
City State ZIP Code •q , \\\;. ..:1
Richlands North Carolina 28574 �,1
Signature / Date Telephone
// '7/7 01/07/2019 [phone]
s l
Copy all pages of thieva tio b/r rtificate and all attachments for(1)community official, (2)insurance agent/company,and(3)building owner.
Comments agyle auipset and location, per C2(e), if applicable)
Prelimi yMl a Iiils'property in an AE 12 zone.
JAN 2 91°19

YI1V:
Pender County Health Department—Environmental Health Division
APPLICATION FOR PERMITS PERMIT#:
Please mail or bring in the first two pages of this completed form,with payment,including the signature of the owner,a floor plan(where applicable)and a
site plan as indicated.Incomplete applications will not be processed.Please speak with our staff if you have any questions about filling out this form.
GENERAL INFORMATION
APPLICANT: Rca 1.-.dc1 (cee-r,e / PROPERTY OWNER: ( a-1 a E�C/�I
ADDRESS: 170 3 Cairo I1,vyl ZIL,C ADDRESS: 6-Zc bU,Ne j
I p5u.il Bead,,mc ze4gs bo(et6G, NC 27(o06
EMAIL: Oa n 9 lvL�iIckes ne..CQM EMAIL: eb&pi-9 fPel3 rn2lf-POrn
PHONE NUMBER: et IO- 6tat- 7`LO 4 PHONE NUMBER:
PROPERTY ADDRESS: I 2.12_ Bart.(k SUBDIVISION/LOT#: L B Dck 4Q
DIRECTIONS: —Mr Bea el..,
1 PROJECT INFORMATION
E6IEW STRUCTURE ❑EXISTING STRUCTURE ❑REPAIR EXISTING SEPTIC OR WELL
❑ABANDON EXISTING SEPTIC OR WELL t❑PERMIT REVISION ❑OTHER• 1(
PROJECT DESCRIPTION: Vep ,r, ISkt-vs h e r2YY.01re LVGLS-14y,.•
C&f,S4tL E i'L vV 6I:v-9LP -�arine I frlb m e t nS-Ja I I n ew Seri-ic s-Fe
ENINGLE FAMILY HOME Number of Bedrooms Number of occupants
❑BUSINESS/OTHER
Please describe the business,number of employees,square footage,etc. Use attachments if necessary. Floor plans
and/or additional info may be required to determine daily design flow.
TYPE OF WATER SUPPLY PLEASE CHECK IF APPLICABLE: CHECK REQUESTED SYSTEM TYPE:
QtUBLIC ❑BASEMENT WITH PLUMBING lCONVENTIONAL
❑PRIVATE WELL ❑WASTEWATER OTHER THAN SEWAGE GENERATED ❑MODIFIED
❑SHARED WELL �❑PROPERTY CONTAINS DESIGNATED WETLANDS ❑ALTERNATIVE
❑OTHER [{d"SITE IS SUBJECT TO APPROVAL BY OTHER AGENCY ❑ANY
❑FACILITY WILL HAVE A GARBAGE DISPOSAL ❑OTHER(specify):
IMPORTANT: IN ORDER FOR YOUR APPLICATION TO BE PROCESSED,YOU MUST ALSO COMPLETE THE FOLLOWING:
SUBMIT A SITE PLAN OR PLAT SHOWING: [EXISTING AND PROPOSED PROPERTY LINES WITH DIMENSIONS
0 ALL EXISTING AND PROPOSED EASEMENTS,RIGHTS OF WAY,CAMA LINES
Er LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES AND DRIVEWAY
Ef LOCATION OF ALL EXISTING AND PROPOSED WELLS AND WATER LINES
PREFERRED LOCATION OF SEPTIC AND/OR WELL.(OPTIONAL)
PREPARE THE SITE: ErCLEARLY MARK EXISTING AND PROPOSED PROPERTY LINES/CORNERS/EASEMENTS;
['STAKE LOCATION OF PROPOSED STRUCTURES/ADDITIONS/DRIVEWAYS;
[14AKE SITE ACCESSIBLE;CLEAR UNDERGROWTH AS REQUIRED.
[]'MARK PREFERRED LOCATION FOR SEPTIC AND/OR WELL. (OPTIONAL)
RECEIVED TT/ �A�, AA''((�� aCALL IN AND NOTIFY OUR OFFICE THAT THE SITE IS STAKED AND READY
*A REVISIT FEE(� 1A -fil,{C�� .Ct INQFTER NOTIFYING US THAT THE SITE IS READY,THE SITE IS FOUND TO NOT BE READY
FOR EVALUATION WHEN THE EHS ARRIVES*
THE FOLLOWING ili TID2 NALVI ORMATION IS REQUIRED WITH APPLICATIONS FOR CONSTRUCTION AUTHORIZATIONS:
QUA FLOOR PLAN OF THE PROPOSED STRUCTURE SHOWING ALL ROOMS ON EACH FLOOR OF THE BUILDING, INCLUDING BASEMENTS.
PLEASE LABEL EACH ROOM AS TO ITS USE, AND SHOW LOCATION OF DOORS AND ANY
STAIRS BETWEEN FLOORS.
QrSITE PLANS FOR CA'S MUST SHOW SETBACKS FROM PROPERTY LINES TO PROPOSED STRUCTURES,LOCATION OF DRIVEWAYS,WATER
SUPPLIES/LINES AND ANY EASEMENTS. SITE PLANS MUST BE PRE-APPROVED BY PENDER
COUNTY BUILDING INSPECTIONS.
El OTHER REQUIRED ADDITIONAL DOCUMENTS SUCH AS TRI-PARTY AGREEMENTS, EASEMENTS, DESIGN PLANS AND SPECIFICATIONS,
ETC. SOME OF THESE DOCUMENTS MUST BE APPROVED BY PCEH AND RECORDED WITH
THE PENDER COUNTY REGISTER OF DEEDS PRIOR TO ISSUANCE OF THE CA.

IMPERVIOUS CALCULATIONS
ZONE: R-3 siTE
HOUSE, PORCHES, EAVES-1821 SQ FT MINIMUM SETBACKS '
GRAVEL DRIVE--756 SQ FT FRONT-7.5' 'I''
TOTAL IMPERVIOUS-1997 SQ FT SIDE-5' 4433-
LOT AREA--5871 SQ FT. REAR—CAMA 30' i tt, ��
% IMPERVIOUS--34.0% ot,
VICINITY MAP No srelF
`T S 45'15'45" E
CANAL /60.48'
D0C1 BULKHEAD
CANAL
a ► A- K K —
SIS
/�� a DECKCK SIS
LO 28 N +
BLOCK 49
MB 10 PG 24,25 IIIIIIIMI
0.13 AC. —
?D'E 'A -- --— -
COVERED 29.3 ><
4H--28 2' __COVERED
m 16'
16' 1
CANTTLEVEREI v
� N
Z 2.7 PROPOSED - t0
LOT 29 2 STORY LOT 27
BLOCK 49 m HOUSE a BLOCK 49
MB 10 PG 24,25 N N * MB 10 PG 24,25
75'AEC UNE -1--'y, 1
O "1 224;v> ` '7 6' .
'"-->'�.:.. PORCH 7'13.3' 6' SET NAIL IN POWER POLE
='"�'� `—'i�= s j,> T— AT 15.00' MSL NAVD 88
L. tit¢_=}i. -i4,%r
7.--_,,...s.ief*,fl:;:j.„
.� „ p a� IEIVED
FlP xuW . E)0§INC�f�RA 1 +4! 1J�IL
N 44 7 w,,;;�.°RIY.711 "• `- NGTO NC
3 '30�`•.. r• ,A../ M I
60.50' A.StY. :. ;� y xS :, I ,
w JAN 292019
FLOOD DATA BORYK AVENUE i
FLOOD ZONE "AE" 60' PUBIC RIGHT—OF—WAY
BASE FLOOD ELEVATION-11'
FREEBOARD=+3'
FINISHED FLOOR TO BE AT 14' OR HIGHER
PRELIMINARY FLOOD MAPS SHOW BFE AT 12'
122 BOYRK AVENUE
PRELIMINARY PLOT PLAN
**FLOOD CERTIFICATION** 30 15 0 30 60
THIS IS TO CERTIFY THAT THIS PROPERTY IS iiiiiiiI I
LOCATED IN FLOOD HAZARD ZONE 'AE' PER
COMMUNITY # 370167 PANED 420z J GRAPHIC SCALE
REVISED 1/24/19--ADDED 75' AEC UNE
'I UU(IIFY THAT THIS MAP WAS DRAWN UNDER MY AL--AREA LIGHT FCM--FOUND CONCRETE MONUMENT i_ ***LE EN D***
SUPERVISION FROM AN ACTUAL SURVEY MADE UNDER CB--CABLE BOX FUN--FOUND MAC NAIL MBL-MINIMUM BUILDING UNE COMPUTED
MY SUPERVISION FROM A DEED RECORDED IN DEED CM--CHIMNEY FlP--FOUND IRON PIPE OHEL--OVERHEAD ELECTRIC UNE I BY COORDINATES
BOOK 4609, PAGE 9541 OR OTHER REFERENCE C/L--CENTERUNE F1S--FOUND IRON STAKE PG___,PAGE SUN--SET MAC NAIL
G__CON�TE FPK--FOUND PK NAIL
SOURCE MAP BOOK 10, PAGE 24,25;THAT THE PP--POWER POLE SPK--SET PK NAIL
BOUNDARIES NOT SURVEYEIMla I . ,a AS CP--COMPUTED POINT --MAP POD Rt.v--RIGHT OF WAY TP--TELEPHONE PEDESTAL
DRAWN FROM INFORMATI 1N_ A 4pAGFN/A DB--DEED BOOK DAB""-W1P 80CK SD--SATELLITEDISH TF--TRANSFORMER
OR OTHER REFERENC tP '' I/; 0&UE--DRNNAGE k llRLf1Y EASEMENT SIS--SET IRON STAKE WM--WATYR METER
THAT THE RATIO OF •'.V, a�"''�-i•�
ACCURACY IS 1:tOQQO �'' SURVEY FOR: GALE W. EBERT AND WIFE JOAN E. EBERT
THE REQUIREMENT=OF i� v M..*�,?,,
PRACTICE FOR L/u1D SU GIN NO• !-OU SUBDMSION: FIFTH SUBDMSION OF NEW TOPSAIL BEACH
(21 NCAC56.1601.' 1/1A11.q .
� GAIRY CANARY SURVEYING
-2904
'� LOT 28 BLOCK. 49 SECTION: N7A P.O. BOX: 915 2780
x
44 PENOER COUNTYTOPSALTOWNSHIP KINSTON HIGHWAY
� 'iIAM� REVISED i/24/19 RICHLANDS, NC 28574
•< DATE t/7/19 SCALE: t'.30' FB 286 OFFlCE:[phone]
J46.1f y �, PCs,- FAX:[phone]
_ _ "c, nmcciummunv ..w,. ,2222- MORIIF•(91F)13R9-RAW)

1
STORMWATER PLAN
BUILDING IMPERVIOUS AREA 1 ,910 SQ. FT.
(INCLUDING 12" ROOF OVERHANG)
VOLUME 1 .5" RAIN IN 24 HOURS 1 ,910 / 8 = 239 CF
BED VOLUME REQUIRED 239 CF / 40% VOIDS SPACE = 598 CF
BED SIZE PROVIDED (1) EA. 2.0' D x 5.0' W x 60.0' L = 600 CF
TOPSOIL
4„ - ..
#57 STONE BED LINED
WITH FILTER FABRIC
i
0
5'-0" i
6" DIA. HDPE PERFORATED PIPE
CONNECTED TO HOUSE DOWNSPOUTS
DRAIN BED SECTION
``%,,,,,,,,,,„
cift
�o..ss'SEAL,p�,% DECEIVED
14 n, ..: _ CN9 WILIIgINGTQN, NC
1. 249/6 = JAN $ 9 2019
�•• /- 2y-1 t ..
SMITH‘
COPYRIGHT 2019 ® SMITH ENGINEERING AND DESIGN, P.A. -ALL RIGHTS RESERVED
PROJECT: Gale & Joan Ebert BULLETIN NO. 1
122 BORYx AVE. SMITH ENGINEERING
TOPSAIL BEACH, NORTH CAROLINA 28445 AND DESIGN, P.A.
1103 Gracie Place Suite'A'
Goldsboro,N.C.27534
DATE: JAN. 24, 2019 PROJECT MANAGER: J. SMITH Corporation License No. C-2241

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2-story house I
I Drain Field I
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RECEIVED water d
DCM WI4.MINGTOV, NC ., � ;�,.
JAN 2 9 2319 i
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Covered Porch '
tt cfe !. ;
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L-- ___.,-- — .I:+w.... ...... .I N445'00 lJ r
^ n,20F — i

Date Date Check From Name of Vendor Check Check Permit Rct.
Received Deposited Permit Holder Number amount Number/Comments
G & G Builders of First
Wendell/Randy Citizens $ minor fee, 122 Boryk JD rot.
1/30/2019 Greene Gale Ebert Bank 38108 100.00 Ave., TB PnCo 7374D