86386A - Moncla, Paul & Kristie

I
NY 86386
Previous permit i �1L�31A
3 GENERAL PERMIT bate previous permit issued 6,"' 3/- /
]New U Modification K Complete Reissue ❑ Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commissloo In an area of environmental concern pursuant to:
I SA NCAC Rules attached. J General Permit Rules available at the following link: www deg.nc•QoyfCAMArules
Appicant Name ��:a 1 ay¢ K ri/��.�t e. one r W Authorized Agent '—
Address S(3T L�0.iZY' \..z-t.%+- Cr _ Project Lx"ticn (County): -1S4 i.ck.
State ZIP a')"1d4 Street Address/State Road/Lot #(s)
Phone # (1�j) �{ 5t o17('P Email Subdivis on a i`I C oar, Pez)4
C"y ZIP 27 ! Q/
Affected CW I EW Q PTA Es PTS Ad(. Wtr. Body CtS4 t.tC'iif 0.+c k s 1lE+Ir / _( at nan/unk)
AEC(s): OEA IHA UW �SPIMA CJPWS Closest Maj. Wtr. Body A Ib *N4" r1? S,,,e-d
ORW: yes, In nnPNA_ yesAD Type of Project/ Astivity, � 'x (o " D I G" Lam((o )c'Q L/ a OJ n (C'i-rc r rv,
d a k�t (Scale: ►"r 3d )
Shoreline Len& *7-
Access Length
Pler (dock) length
Fixed Platform(s) �Ie i x;y f - -
'_ T 1 -1 4
f
1
1 I
1 1 F 1 1
Floating Platform(s) 1 1
Finger piers)_
Total Platform area
Groin length/#
+ +
f I
Bulkhead/ Riprap length
Avg distance offshore
1—t-^-,- --
- - -I -
`
T
Breakwater/Sill
Max distance/ length
1 �
Basin, channel
I f l l i
Cubic yards
r-r-
Boat rampIF
�-
Boathouse/ Boatl-rft
I
Beach Bulldozing
Other �Ctt n•
��
_ i _
f__� -i_.
SAV observed;
yes
no ' T-- ► -/- ""
i 1 1
Moratorium: n/a
yes
no
Site Photos:
yes
no Wt 4 ewo
Riparian Waiver Attached:
yes
no � _ - 1
�'- - -
A building permiVzoning permit may be required by
Permft Conditions
_ 1 I I
1 I 1 • I : Y i I
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� Ir+ ► j s I 1 r 1 1
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r
i . 4 i I 1 1 1 r 1
1 . 1
1 1' I_ 1- i 1 I 1 1 '1 1
. - r •'- r`T. -•"r--7-' 1- ,-_'-.T..r -'-r--.-�-r -
i
-� TAR/PAM/NEUSE/BUFFER (cirde one)
See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
0 --, c-
Agent or Applitant PRINTED Namg / Permit Offic 6 PRINTED Name I
4VLJ- one rr - ` it - `z--- `7 Leh . r<✓►
Signature "Please read compliance stat ent on back of permit" Signature
s aco. � AJIIV a2 4/ 20 /22 � i2
Applicabon Fec(s) Check p/Money Order Issuing Date Expiration Date

RECEIVED N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
APR 13 2022 CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
DCM-EC ri
Name of Property Owner: U.,on c
Address of Property: J�() tp � e �C- CbLItF
Mailing Address of Owner: so S \A)4 r ('jrs+ rd
/-
Owner's email: �cmr�t i[k1� �i� `1 Owner's Phone#: QL 1�'
Agent's Name: Agent Phone#:
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
permit has described to me, as shown on the attached drawing, the development they are proposing. A
I DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at [phone]. No response is considered the same as no objection if you have been
notified by Certified Mail.
WAIVER SECTION
I understand that any proposed 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
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setbacKA�i
LW /. Q ,�
Signature of Adjacent Riparian Property Ov n r
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner: // f'WVV 'l. U- FiJJyjv% Gr-j/
Typed/Printed name of ARPO:
Mailing Address of ARPO: rrl l 6otA C
ARPO's email: ih pf\A-Mli 064e ARPO's Phone#:
)AKA 1. ca►r.—
Date: 3' �'SI ZZ *waiver7s valid for up to one year from ARPO's Signature*
Revised July 2021

TIPS FOR ADJACENT RIPARIAN OWNER NOTIFICATION & WAIVER FORMS
CAMA Regulations require notice of proposed development to the Adjacent Riparian Property Owners (15A
NCAC 7J.0204(b)(5)). Proof of actual notice (a sign -off by the owner on this form) or certified mail return
receipts (showing delivery of notice) are needed.
The purpose of this notice is to make adjacent riparian property owners aware of the proposed development
so that they have an opportunity to provide comments (or potentially object to) the proposed development,
and to give DCM an opportunity to consider these comments/objections before a permit decision is made.
"Permission" of adjacent property owners is not necessarily required for DCM to issue a permit; however,
permission must be obtained for certain types of proposed developments if they fall within a 15' setback area
along the riparian access area of the adjacent property, as determined solely by DCM. It is in the applicant's
best interest to provide comprehensive and accurate notice so that any concerns or objections can be
resolved early in the permit review process. In addition, if the adjacent riparian property owner appeals the
permit decision, insufficient notice could be a basis for granting such an appeal.
Who is an Adjacent Riparian Property Owner?
What is Adjacent? (Note: DCM reads this broadly to ensure comment by potentially impacted neighbors)
• A property that shares a boundary line with the site of proposed development; AND
• A property that fronts a natural or manmade waterbody that is connected to coastal waters and
can support some form of navigation, even a kayak or canoe, including a common canal system
or a manmade basin.
• Easement holders? Yes, if the easement could be impacted by the proposed development.
• Streets/Roads? Only if the street/road could be impacted by the proposed development. This
might include street -ends which might be used for parking and beach access.
• Holders of recognized submerged lands claims/shellfish franchises.
What is Riparian?
Do the boundaries of the adjacent property legally intersect with the water at mean high tide? If there is a
question about whether an adjacent property is considered "riparian," please reach out to DCM Staff -
especially on the oceanfront beach where there may be undeveloped parcels on the beach or in the water.
Who/What is a Property Owner?
For private individuals (or families), send notice to the address listed on the tax card. If the property is owned
by an Inc. or LLC, please send notice to the person listed as the registered agent on the NC Secretary of
State's Corporations Look Up site: https://www.sosnc.gov/search/index/corp. For Condominiums or
neighborhoods with an owners' association (HOA/POA), send notice to the association (which is usually a
corporation, for which you send notice to its registered agent).
What is Notice, and how do I ensure it is received?
• You can meet with your adjacent property owner, provide a description or drawing of the
proposed development, and ask them to sign this form and return it to DCM; OR
• You can hand -deliver this form and a description or drawing, and ask your neighbor to return it to
DCM (consider providing them with a stamped envelope); OR
• You can mail this form by USPS Certified Mail, return receipt requested (the Green Card). If you
choose this option, you must provide either the signed & returned green card OR track the
certified mail package number on USPS.GOV's online tracking system, and provide the tracking
print-out as proof of delivery to DCM
If you have any questions about this process, please reach out to DCM Staff and DCM Legal Counsel
and we will work to answer your questions.
Revised July 2021

BOOK 1431 PAGE 722 (3) —;^ °- `t j (1&�ASQUQ�'ANK COUNTY
3EEV D GCS
468197 Deed number Al
APR 2 0 2022 Transfer tax $
Dei' ent tax $
This document presented and filed:
1 � C Pa trot nl. ',) _ ,kssessor's once
11/12/2021 02A9:56 PM
CLEMENTINE WHITE, Pasquotank County, NC
Excise Tax: $158.00
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax:
Parcel Identifier No.: Out of 893303007102 (Out of P124A-49)
Verified by Pasquotank County on the day of 20 By:
Mail/Box to: THOMPSON & PUREZA, P.A.
This instrument was prepared by: THOMPSON & PUREZA, P.A., tot West Main Street, Elizabeth City,
NC 27909 (2021-369)
Brief description for the Index: Part of Lot 49A, Pelican Pointe Subdivision
THIS DEED made this 18th day of October, 2021, by and between
GRANTOR
JON S. CROUSE and wife,
DONNA W. CROUSE
GRANTEE
RHONDA B. TWIDDY
310 Harrier Court
Elizabeth City, NC 27909
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors, and
assigns, and shall include singular, plural, masculine, feminine or neuter as required by context.
WITNESSETH, that the Grantor, for a valuable consideration paid by the Grantee, the receipt of which is
hereby acknowledged, has and by these presents does grant, bargain, sell and convey unto the Grantee in fee
simple, all that certain lot or parcel of land situated in Nixonton Township, Pasquotank County, North
Carolina, and more particularly described as follows:
See "EXHIBIT A" attached hereto and made a part hereof.
Per N.C.G.S. §105-317.2, the property herein described does not include the primary residence of Grantor.
This document was prepared by David R. Pureza, a licensed North Carolina attorney, without title
examination, closing or tax advice. Delinquent taxes, if any, to be paid by the closing attorney to the County
Tax Collector upon disbursement of closing proceeds.
The property hereinabove described was acquired by Grantor by instrument recorded in Book 816, Page 728.
A1map showing the above -described property is recorded in Map Book 41, Page 5, and Map Book, Page

BK 1431 PG 723 DOC#468197
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto
belonging to the Grantee in fee simple.
And the Grantor covenants with the Grantee, that Grantor is seized of the premises in fee simple, has the right
to convey the same in fee simple, that title is marketable and free and clear of all encumbrances, and that
Grantor will warrant and defend the title against the lawful claims of all persons whomsoever, other than the
following exceptions:
Ad valorem taxes for the current and subsequent years
Easements, restrictions and rights -of -way of record
IN WITNESS WHEREOF, the Grantor has duly euted the
written.
S. CROUSE
DONNA W. CROUSE
of the day and year first above
(SEAL)
(SEAL)
State of North Carolina - County of 0
lf-�
I, the undersigned Notary Public of the County or City of fit% and State aforesaid,
certify that JON S. CROUSE and wife, DONNA W. CROUSE, p rsonally appeared before me this day and
acknowle she due execution of the fo going instrum t for the purposes therein expressed. Witness my
han�, a�T0 a0� 61amp or seal this day of �i 9PiV , 2021.
Q"- s
O STAR ?9:
B1�x Seal) U
C�J?�,,,
'Ia.,„lault'u..o Notary Public
My Commission Expires: �� ��

BK 1431 PG 724 DOC#468197
EXHIBIT A
(Crouse to Twiddy)
All that certain lot or parcel of land situated in Nixonton Township, Pasquotank County,
North Carolina, and more particularly described as follows:
That certain tract or parcel of land described, delineated and designated as "ADDITION TO
LOT 48A 13,840 SQ.FT. TO BE CONVEYED" on that certain plat entitled in part,
"RECOMBINATION SURVEY FOR RHONDA TWIDDY and PAUL R. MONCLA and
KRISTIE E. MONCLA FORMERLY LOTS 48A, 49A and 5oA OF PELICAN POINTE
SUBDIVISION — (P.B. 41, PG. 5)", dated 10/27/2021, revised ii/o8/2021, prepared by
Thomas A. Stokely, Professional Land Surveyor, a copy of which plat is recorded in Map
Book ��, Page 24- , Pasquotank County Public Registry, and is incorporated herein
by reference.
The above -described property is a portion of "Lot 49A" as described, delineated and
designated on that certain plat recorded in Map Book 41, Page 5, Pasquotank County
Registry (PIN: 893303007102 (Map: P124A-49) and shall be recombined with "Lot 48A"
as described, delineated and designated on plat recorded in Map Book 41, Page 5,
Pasquotank County Registry (PIN: 893303oo6291 (Map: P124A-48).
The resulting parcel is described, delineated and designated as "LOT 48A-R 41,942.89
Sq.Ft. o.96 AC." on that certain plat entitled in part, "RECOMBINATION SURVEY FOR
RHONDA TWIDDY and PAUL R. MONCLA and KRISTIE E. MONCLA FORMERLY LOTS
48A, 49A and 5oA OF PELICAN POINTE SUBDIVISION — (P.B. 41, PG. 5)", dated
10/27/2021, revised 11/o8/2021, prepared by Thomas A. Stokely, Professional Land
Surveyor, a copy of which plat is recorded in Map Book 616 , Page ?-Z. , Pasquotank
County Public Registry, and is incorporated herein by reference. The resulting parcel shall
have an address of 310 Harrier Court and shall be designated as PIN: 893303oo6291(Map:
P124A-48) in the Pasquotank County Tax Office.
CEIVED
APR 2 0 2022

eoox 1431 ancE 725 (J)
This document presented and filed:
11/12/2021 02:52:55 PM
C sue: cam." --
CLEMENTINE WHITE, Pasquotank County, NC
Excise Tax: $158.00
Excise Tax:
PAS UOTAN K(COUNTY
Deed num� iber as
Transfer tax $
Peyifinent tax $
1'algtu,tac !, t oueity lssesu►rs Office
NORTH CAROLINA GENERAL WARRANTY DEED
Parcel Identifier No.: Out of 893303007102 (Out of P124A-49)
Verified by Pasquotank County on the day of , 2o_ By:
Mail/Box to: THOMPSON & PUREZA, P.A.
This instrument was prepared by: THOMPSON & PUREZA, P.A., ioi West Main Street, Elizabeth City,
NC 27909 (2021-369)
Brief description for the Index: Part of Lot 49A, Pelican Pointe Subdivision
THIS DEED made this 18th day of October, 2021, by and between
GRANTOR
JON S. CROUSE and wife,
DONNA W. CROUSE
77-1 i51'm
PAUL RICHARD MONCLA and wife,
KRISTIE EADIE MONCLA
505 Watercrest Circle
Elizabeth City, NC 27909
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors, and
assigns, and shall include singular, plural, masculine, feminine or neuter as required by context.
WITNESSETH, that the Grantor, for a valuable consideration paid by the Grantee, the receipt of which is
hereby acknowledged, has and by these presents does grant, bargain, sell and convey unto the Grantee in fee
simple, all that certain lot or parcel of land situated in Nixonton Township, Pasquotank County, North
Carolina, and more particularly described as follows:
See "EXHIBIT A" attached hereto and made a part hereof.
Per N.C.G.S. §105-317.2, the property herein described does not include the primary residence of Grantor.
This document was prepared by David R. Pureza, a licensed North Carolina attorney, without title
examination, closing or tax advice. Delinquent taxes, if any, to be paid by the closing attorney to the County
Tax Collector upon disbursement of closing proceeds.
The property hereinabove described was acquired by Grantor by instrument recorded in Book 816, Page 728.
A map showing the above -described property is recorded in Map Book 41, Page 5, and Map Book roe , Page
APR 2 0 2022
q-Ci

BK 1431 PG 726 DOC#468198
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto
belonging to the Grantee in fee simple.
And the Grantor covenants with the Grantee, that Grantor is seized of the premises in fee simple, has the right
to convey the same in fee simple, that title is marketable and free and clear of all encumbrances, and that
Grantor will warrant and defend the title against the lawful claims of all persons whomsoever, other than the
following exceptions:
Ad valorem taxes for the current and subsequent years
Easements, restrictions and rights -of -way of record
IN WITNESS WHEREOF, the Grantor has duly;ON
juhaf ing as of the day and year first above
written.
(SEAL)
. CROUSE
&w-&' COX41--- (SEAL)
DONNA W. CROUSE
State of North Carolina - County of
I, the undersigned Notary Public of the County or City of U and State aforesaid,
certify that JON S. CROUSE and wife, DONNA W. CROUSE, pe sonally appeared before me this day and
acknoWlndV4 the due execution of the for oing instrWnq4 for the purposes therein expressed. Witness my
404 44d F% ,,stamp or seal this day of , 2021.
V _
ate; 01 .9
U
:.ffix Seal) Z
,
� AVB`�
00
jail c n
My Commission Expires:
otaaPublic

BK 1431 PG 727 DOC#468198
EXHIBIT A
(Crouse to Moncla)
All that certain lot or parcel of land situated in Nixonton Township, Pasquotank County,
North Carolina, and more particularly described as follows:
That certain tract or parcel of land described, delineated and designated as "ADDITION TO
LOT 5oA 13,840 SQ.FT. TO BE CONVEYED" on that certain plat entitled in part,
"RECOMBINATION SURVEY FOR RHONDA TWIDDY and PAUL R. MONCLA and
KRISTIE E. MONCLA FORMERLY LOTS 48A, 49A and 5oA OF PELICAN POINTE
SUBDIVISION — (P.B. 41, PG. 5)", dated 10/27/2021, revised ii/o8/2021, prepared by
Thomas A. Stokely, Professional Land Surveyor, a copy of which plat is recorded in Map
Book J(gL, Page, Pasquotank County Public Registry, and is incorporated herein
by reference.
The above -described property is a portion of "Lot 49A" as described, delineated and
designated on that certain plat recorded in Map Book 41, Page 5, Pasquotank County
Registry (PIN: 893303007102 (Map: P124A-49) and shall be recombined with "Lot 5oA"
as described, delineated and designated on plat recorded in Map Book 41, Page 5,
Pasquotank County Registry (PIN: 893303007023 (Map: P124A-50).
The resulting parcel is described, delineated and designated as "LOT 5oA-R 43,36o.16
Sq.Ft. 1.00 AC." on that certain plat entitled in part, "RECOMBINATION SURVEY FOR
RHONDATWIDDY and PAUL R. MONCLA and KRISTIE E. MONCLA FORMERLY LOTS
48A, 49A and 5oA OF PELICAN POINTE SUBDIVISION — (P.B. 41, PG. 5)", dated
10/27/2021, revised ii/o8/2021, prepared by Thomas A. Stokely, Professional Land
Surveyor, a copy of which plat is recorded in Map Book (06 , Page Z2 , Pasquotank
County Public Registry, and is incorporated herein by reference. The resulting parcel shall
have an address of 3o6 Harrier Court and shall be designated as PIN: 893303007023
(Map: P124A-50) in the Pasquotank County Tax Office.
RECEIVED
A P R 1 0 P022

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RECE'V N.C. DIVISION OF COASTAL MANAGEMENT
CENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
APR 13 20P2 CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
('°
(Top portion to be completed by owner or their agent)
D C �fI;EQroperty Owner: _PCu \ '� V\ r1 -C � t� 0( k
Address of Property: 30 W "a _ C ►f f COL (A
Mailing Address of Owner: � � ,J c k c l cec_4 L a- e­
.�,CD^r,N (I
Owner's email: i�r�S%[ rY1G1L1G��1 � ,�'(A` Owner's Phone#:c.�- ,�5'S9_7
Agent's Name:
Agent's Email:
Agent Phone#:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
permit has described to me, as shown on the attached drawing, the development they are proposing. A
description or drawing with dimensions must be provided with this letter.
I DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at [phone]. No response is considered the same as no objection if you have been
notified by Certified Mail.
WAIVER SECTION
I understand that any proposed 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
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback " `,
A &( 8,
Signature of Adjacent Ri arian Property O ner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: Ml r I of I'y1 t i)Qrrll
Mailing Address of ARPO: I�� f te-
Cp
ARPO's email: G �I�L.t h�(X iT�Q [ ,II Al2P�'s Phone#:
Date: *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

TIPS FOR ADJACENT RIPARIAN OWNER NOTIFICATION & WAIVER FORMS
CAMA Regulations require notice of proposed development to the Adjacent Riparian Property Owners (15A
NCAC 7J.0204(b)(5)). Proof of actual notice (a sign -off by the owner on this form) or certified mail return
receipts (showing delivery of notice) are needed.
The purpose of this notice is to make adjacent riparian property owners aware of the proposed development
so that they have an opportunity to provide comments (or potentially object to) the proposed development,
and to give DCM an opportunity to consider these comments/objections before a permit decision is made.
"Permission" of adjacent property owners is not necessarily required for DCM to issue a permit; however,
permission must be obtained for certain types of proposed developments if they fall within a 15' setback area
along the riparian access area of the adjacent property, as determined solely by DCM. It is in the applicant's
best interest to provide comprehensive and accurate notice so that any concerns or objections can be
resolved early in the permit review process. In addition, if the adjacent riparian property owner appeals the
permit decision, insufficient notice could be a basis for granting such an appeal.
Who is an Adjacent Riparian Property Owner?
What is Adjacent? (Note: DCM reads this broadly to ensure comment by potentially impacted neighbors)
• A property that shares a boundary line with the site of proposed development; AND
• A property that fronts a natural or manmade waterbody that is connected to coastal waters and
can support some form of navigation, even a kayak or canoe, including a common canal system
or a manmade basin.
• Easement holders? Yes, if the easement could be impacted by the proposed development.
• Streets/Roads? Only if the street/road could be impacted by the proposed development. This
might include street -ends which might be used for parking and beach access.
• Holders of recognized submerged lands claims/shellfish franchises.
What is Riparian?
Do the boundaries of the adjacent property legally intersect with the water at mean high tide? If there is a
question about whether an adjacent property is considered "riparian," please reach out to DCM Staff -
especially on the oceanfront beach where there may be undeveloped parcels on the beach or in the water.
Who/What is a Property Owner?
For private individuals (or families), send notice to the address listed on the tax card. If the property is owned
by an Inc. or LLC, please send notice to the person listed as the registered agent on the NC Secretary of
State's Corporations Look Up site: https://www.sosnc.gov/search/index/corp. For Condominiums or
neighborhoods with an owners' association (HOA/POA), send notice to the association (which is usually a
corporation, for which you send notice to its registered agent).
What is Notice, and how do I ensure it is received?
• You can meet with your adjacent property owner, provide a description or drawing of the
proposed development, and ask them to sign this form and return it to DCM; OR
• You can hand -deliver this form and a description or drawing, and ask your neighbor to return it to
DCM (consider providing them with a stamped envelope); OR
• You can mail this form by USPS Certified Mail, return receipt requested (the Green Card). If you
choose this option, you must provide either the signed & returned green card OR track the
certified mail package number on USPS.GOV's online tracking system, and provide the tracking
print-out as proof of delivery to DCM
If you have any questions about this process, please reach out to DCM Staff and DCM Legal Counsel
and we will work to answer your questions.
Revised July 2021

XCAMA / .-ii DREDGE & FILL
r. GENERAL PERMIT
XNew ]Modification -'Complete Reissue ❑Partial Reissue
a Qi B C D
Previous permit #
Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC 171,1
ARules attached.
Applicant Name l J d K { t5 e_ Aen nd(A Project Location: County P-6i S) L r,k- A.K-
Address 61_ h_01_ -11 (� t .5 r , Street Address/ State Road/ Lot #(s) 4 * q /
City 1►-u'y '_41 C'k-t, State_��ZIP �t % <-� � rr1er �-'� .
1�r:�►� Phone # (�� ri � .i� ��� E-Mail Subdivision �O�kc Cz�' l
Authorized Agent City C'.' ZIP 2'11 o9
Affected ❑ CW W EW [Y PTA ❑ ES ❑ PTS
AEC(s): ❑ IDEA L: HHF IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / no' PNA yes /n
Phone # ( ) River Basin
n
Adj. Wtr. Body V')4ic'(Aark LLMg-(61_2Vran /unkn)
Closest Maj. Wtr. Body ja ( 6e-Mc.r tt SVL.J
Type of Project/Activity (Ii:n'� k-rL.Ck- c� �( � Y �1►c r ( i ,� Yl '/ l "/ elajiarcl
r'
d L A I't �x I i, S (Scale: I =3 )
Pier (dock) lei
Fixed Platforn
Floating Platfc
Finger pier(s)_
Groin length
number
Bulkhead/ Rip
avg dista
max dist
Basin, channe
cubic yai
Boat ramp
Boathouse/ B4
Beach Bulldog
Other_
Shoreline Len
SAV: n
Moratorium:
Photos:
Waiver Attacl
A building permit may be required by: 1 �� � lye k. r. `` . L-1 _, ❑ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
3 (Y
APR 13 201
Permit ice 's Printed Name
Signatu
�3 /Z.J )' /3/�,I
Application Fee(s) Check# 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
Neuse River Basin Buffer Rules
Other:
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/ 1-888ARCOAST
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

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