Rouse, C. David 77016C

Mail - Derek smith - Outlook
_ 4CAMA / DREDGE a FILL
NERAL PERMIT N° 7?OA B D+' 1Modificauon -Com a Previous permit N �—' et Ketssue —Partial Reissue
As authorised by the State of Noah Carolina, De Dale previ i per it Issued
and the Coastal Resou Comani part^tent d Environmental Quality /� WO
^O^ in anLf ern pursuant oo ISA NGCIF�V`�lApplican[Name Adores$PrrrOaeject,,ggrtL���00n: CountyCiryStatek d State Road/l,u l !)Phone #-M I1 _mtopAuthorized AtAn .�.r d I�.O19:7 4 n
�/ �=H
Affected ❑CW !W IXF A ❑ei ❑FU
AEC(a): OO" UMNf OIH OURA ❑WA
ORW: yes /CV PNA ya
TYPe of Project/ Activity
PRer(dotkl length
-
FloaungPhdoinals)
G�m Wish
number_
BWkhaad/ltipnp krijth ��
avg dktance oRshon
Max distance offshorey`
Bast coastal
cubic yards
Box nmp _ 1 _
Beath
Other
SAY: rot are yes no
Moratorium:
Na yes no
phot06 it,
Waiver Attached: ® -
A budding permit may be required by;
( Note Local Plannmg)urisdiction) n n
Phone #V, /
Adj. Wtr. Body
Closest Mal. Win Body _
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N 0C___ T _
Basin
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.- s.. note on backregarding Itivar BolinrWa 1
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® CAMA / ❑DREDGE & FILL NO 77016
A B D
NERAL PERMIT Previous permit#
w ❑Modif cation ❑Coifiplete Reissue [-]Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality J d ',/ Pv`)O
and the Coastal Resour es Commission in an are of en . nmental concern pursuant to 15A NCAC (� C'S
_ / ❑/Rules atta d.
Applicant NameOD� 5 . ' Project Location: County
Address Stree ddress/ St to Road/ Lo (s)
City '�- �y State P
IV
Phone # (�1 i _ Subdivisioo n r A ..�
Authorized Agent
Affected ❑ CW )�EW U &TA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
Cl PWS:
ORW: yes / PNA yes / n
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SnS ture "* ase read compliance statement on back o erm((it'/'/"
$Application Fee(s)Check#

ry
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 I) 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 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 comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST
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/cmldcm-home
Revised 7/06117

AGENT AUTHORIZATION FOR LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: �4_ ?J,*Vj ' A&e—
MailingAddress: -7�5'4 4►we-
Phone Number:
Email Address:
I certify that I have authorized
to act on my behalf, for the purpose of applying for and obtaining all LAMA permits
r '
necessary for the following proposed development: ,�,J x �$ �+✓►� ��
K
at my property located at ZDZ
in r¢ Countyr
t 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:
Title
. I I 11-i dLC
Date
This certification is valid through l %
bivefioa LZb4LllZZGZT 4L .mo13 WOO 0ZOZ-40-0nv

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ADJACENT RIPARIAN.pROPERTY OWNER STATEMENT
I hereby certify that l own property adjacent to !� ]�A V r � u_ 's
(Namo of property Owner)
Property located at ^o -, c�.__ ".1/ sz
on in
(Waterbody)
N.C.
The applicant has described to me, as shown below, the development proposed at the above
I dory
V I have no objection to this proposal.
1 have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
Ondlvldual propooing dsysfopment must fill In deaerlpfion below or attach a site drawing/
U
W( I21,;q TION
i understand that a pier, dock, mooring plilnpa, boat ramp, breakwater, boathouse, it, or groin
must be set back a minimum dlgtww of 15' from my area of tipaslan access unless waived by
me. (if you y�Ish to waive the setback, you must Initial the appropriate blank below.)
I do wish to walve the I5'setback requirement.
� I do not wish to waive the 15' setback requirement.
(Property
Dare
(Adjacent Proporty Owner IrHormatlon)
VeNd for one caieederyear aner signature' O%Vh adAug. YAfy
blb.en�d L :eosg OH:000zoz-40-onv

ADJAMAT RIPARIAN PROPERTY OWNER ST TTM*KT
I hereby oedfy that i bwtl property adjaeard to _tA1 miyzn • c s e
(None of PropgrV Owner)
property krcafed at .sZO� _sW� „%C el/57.
on &fee- Sye/d
(Waterbo"
N.C.
The applicant has described to me, as shown below, the development proposed at the above
I have no objection to this proposal.
I have objections to this proposal
MSCRIPTION ANOAOR DRAWING OF PROPOSED 0
(��Y���-�✓)�(� {7(Qi
i3 AiUev"II
WAIVFA SECTION
1 urlderetand that a der, dock, mooring painga, boat ramp. breakwater, boathouse, Ilk or groin
must be set back a minimum d%tanee o1 15' hom my area of ripaden access unless wahred by
ma. (H you wish to waive the sathack, you ravet Initial fAo approphato blank below.)
co© / I do With td WHNe the lb' tiMack requirement
Dace
1 do qOt wish to waive Iha I W sa11NIClr requirement.
(Adjoeartt Proparty Owner Inlororotton)
Signow.e�
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