Koutlas, Ted 87326C

❑LAMA ❑ DREDGE & FILL N9 87326 A B C D
Previous permit
3 GENERAL PERMIT Date previous permit issued
New ❑ Modification ❑ Complete Reissue []Partial Reissue
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:
15A NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: wwwdeq nc Rov/CAMArules
Applicant Name
Address
City State ZIP
Phone #
Email
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s) _
Subdivision
City
Affected ❑ cW i `/i EW PTA % ES ❑ PTS Adj. Wtc Body (nat/man/unk)
AEC(s): ❑OEA LEI\IHA UW / SPIMA ❑PWS Closest Maj. Wtc Body
ORW: yes(no PNA: yes /noiyi -
i-
Type of Project/ Activity r
i
(Scale:;!!)
110FE FIE cueau
Access LengthPier
)
( l�ml,
�
—
-
I
\
I_
rgth
Fixed Platfo%
t
„
_
Floating Platform(s)
Finger pier(s)
i
_
Total Platform area
Groin length/# •____. i._._'-_
_
_.__..
Bulkhead/Riprap length
i
�-
F----
--�"--
-
""
-
-
Avg distance offshore ----
---
_
Breakwater/Sill
Max distance/ length
r
Basin, channel
T�
----
I
_
Cubicyards
`�
"-
-
Boat ramp ,� ..,-__-_.
i
{
r1
_
�
Boathouse/ Boatlik
Beach Bulldozing -
-
)
Cl(
"It
1'
•J_
.�'I.
_
_
_
_
_
Other
-
-
It
-
—
1
SAV observed: yes no
Moratorium: n/a yes no
Site Photos: yes no`"-
Rioarian Waiver Attached: ves no
A building permit/zoning permit may be required by:
Permit Conditions
❑ TAR/PAM/NEUSE/BUFFER (circle 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.
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
J
Signature
/ 11
Issuing Date Ex nation Date
Signature '*Please read compliance statement on back of permit"
1' 4 S'
Application Feels) Check #/Money Order
(Please Initial)

Statement of Compliance and Consistency
This permit is subject to compliance with this application and permit 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 from the adjacent riparian property owner(s)
has been obtained, or proof of delivery of certified mail notification of the adjacent riparian property owner(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 1-1 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. If you have any questions, please contact the Division of Water Resources at the
Washington Regional Office (252-946-6481) or the Wilmington Regional Office (910-796-7215).
Notes/Additional Permit Conditions:
Please ensure all debris associated with the removal or construction of the permitted development is contained within the authorized
project area and disposed of in an appropriate upland location.
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 — south of the Neuse River, Onslow
Counties)
Elizabeth City District
401 S. Griffin St. Ste. 300
Elizabeth City, NC 27909
252-264-3901
(Serves: Bertie, Camden, Chowan, Currituck, Dare, Gates, Hertford,
Pasquotank and Perquimans Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Washington District
943 Washington Square Mall Washington, NC 27889
252-946-6481
Fax: [phone]
(Serves: Beaufort, Craven — north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext. Wilmington, NC 28405-3845
910-796-7215
Fax:[phone]
(Serves: Brunswick, New Hanover and Pander Counties)
Revised 6/01/2021

❑CAMA ❑ DREDGE & FILL N9 87326 A B C D
3 GENERAL PERMIT Datep°e ipermit permitissued
❑New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue
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 ❑ Rules attached. ❑ General Permit Rules available at the following link: wwwdeq nc goy/CAMArules
Applicant Name
Address
City
Phone #
Email
ZIP
Affected ❑ CW ❑ EW ❑ PTA 1:1 ES ❑ PTS
AEC(s): ❑OEA ❑IHA ❑UW I❑SPIMA ❑PWS
ORW: yes/no PNA: yes/no
Type of Project/ Activity
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(!
Subdivision
City
Adj. Wtr. Body
Closest Maj. Wtr. Body
............. -..e..
Access Length
Pier (dock) length
Fixed Platform(s)
_....
._._
,..,
_.....
_ _.I
.
-
-.
- _.
\�
I
Floating Platform(s)
Finger pier(s)
Total Platform area
Groin length/M
Bulkhead/ Riprap length
i
Avg distance offshore
Breakwater/Sill
Max distance/ length t-
Basin, channel
Cubic yards_-._
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
!
4
-
!
,
I
7-
I
r
--
,
,i
.�
r
.(..�..-17�
\
(
-
/
t
t
At
!�
..�
l(+.
_
_
-�
+
I
t
__
SAV observed: yes no
Moratorium: n/a yes no
Site Photos: yes no -}-
RinnrianWaiverAttaahed- ves no
--
A building permit/zoning permit may be required by:
Permit Conditions-'.
❑ TAR/PAM/NEUSE/BUFFER (circle 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.
Agent or Applicant PRINTED Name
Signature -'Please read compliance statement on back of permit-*
Application Feels) Check Jt/Money Order
Permit Officer's PRINTED Name
Initial)
1
Signature 7;
Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application and permit 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 from the adjacent riparian property owner(s)
has been obtained, or proof of delivery of certified mail notification of the adjacent riparian property owner(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:
1-1 Tar - Pamlico River Basin Buffer Rules 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. If you have any questions, please contact the Division of Water Resources at the
Washington Regional Office (252-946-6481) or the Wilmington Regional Office (910-796-7215).
Notes/Additional Permit Conditions:
Please ensure all debris associated with the removal or construction of the permitted development is contained within the authorized
project area and disposed of in an appropriate upland location.
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 —south of the Neuse River, Onslow
Counties)
Elizabeth City District
401 S. Griffin St. Ste. 300
Elizabeth City, NC 27909
252-264-3901
(Serves: Bertie, Camden, Chowan, Currituck, Dare, Gates, Hertford,
Pasquotank and Perquimans Counties)
Washington District
943 Washington Square Mall Washington, NC 27889
252-946-6481
Fax: [phone]
(Serves: Beaufort, Craven — north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext. Wilmington, NC 28405-3845
910-796-7215
Fax:[phone]
(Serves: Brunswick, New Hanover and Fender Counties)
http://portal.ncdenr.org/web/cm/dcm-home Revised 6/01/2021

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: e C( V eJk) e S
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
� 1) ° - - 3S`"tg -
Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: A el) S�J� t dDel I
at my property located at I�r—
in Q,-,, �e+-- County.
I furthermore certify that 1 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:
l
SignatuM
I e�( u f 16 5
Print or Type Name
Title
(o 3 1 15 lam_
Date
RECEIVED
This certification is valid through 03 1 /S 1 MAR 3 0 Z022
DCM-MHD CITY

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: l Cef voi-HO-5
Address of Property: Z (% ?u ,( 0 (—
Mailing Address of Owner: 2-1�l
Owner's email:
Owner's Phone#: 5 0 9
Agent's Name: Ct 1'� I Agent Phone#: ZSZ-UZZ-�Y°3
Agent's Email: ��U zY Z Clr c l C u
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
( 1 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 400 Commerce Ave., Morehead City, NC 28557. 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 revetmen ). (If you ish to waive the setback, you must sign
the appropriate blank below.) (\�`
I DO wish to waive some/all of the 15' setback
Signature Adjacent Riparian Property Owner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner: r /�
[ARPO's
Printed name of ARPO: C V 1 t ( �f fl r ( `�
Address of ARPO: u ' L�
�J�fl, kl�eA JC Cbfv✓alt;5l 6+r' a 1
email: ARPO's Phone#: L1 *waiver is valid for up to one year from ARPO's Signature*
Revised)
o/
MAP 3 © 2022
DCM-MFiD CITY

f��

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: Ted
Address of Property:
Zl�
I�s�
Or
Mailing Address of Owner:
%
or
Owner's email:
Agent's Name:
Agent's Email: r GICy� —ti
Owner's Phone#: Sol - ea r- Is-(9
Agent Phone#: 7-5 Z'e% 2 Z e)`(,)3
,Cv^
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.
J P P j P P
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 400 Commerce Ave., Morehead City, NC 28557. 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 ' -
Signatu f djacen Ri airan Prop rty Owner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name ofARPO: �� N k'�C) 1 `%��
Mailing Address of ARPO: \ �;� C�l'lC+�
CMu,1 C'u
ARPO's email: �: \ \I��� (c ARPO's Phone#: IC -, I l lc
Date: waiver is valid for up to one year from ARPO's Signature* _
Revised May
MAR 3 0 2027
DCM-MHD CITY

RECEIVED
MAR 3 0 2022
DCM-MHD CITY

Cashier: Open
Terminal: Cash Out
Date: 9/30/2021
Time: 9:38:09 AM
Invoice: 17085
MICKY PENNY
3 B MAYBERRY LOOP RD
!head City, NC 28557
le: [phone]
Express Auto Care
Store: 0001
4311 Arendell Street
Morehead City, NC 28557
[phone]
StatelD: NC
11 Chevrolet Silverado 1500 LT
gine: V8 4.81 294cc FI (16V) OHV FLEX VIN:A Eng Code:1-20 Vortec
1:3GCPKSEA6BG203530
de: HN4414 (NC)
licle No: HN4414
rrent Odometer: 143,008
turn Odometer: 148,008 Return Date: 2/28/22
Service Name Service Description List Price Net Price
SYNPOWER - $69.95 SYNPOWER FULL SYNTHETIC $78.20 $78.20
VO-88 YALYOLINEOIL FILTER Oty.1.00ea.
SYNPWH5W30 YALYOLIN£SYN5W30API SN Oty600qt. Upcharao$8.25
FSLabor FSLaborCharge Oty1.00ea.
Tech Oty 1.00 ea.
Legacy Checklist
1. Oil Change
COMPLETE
2. Oil Filter
COMPLETE
3. Air Filter
CHECKED & OK
4. Transmission
FULL
5. Coolant
FULL
6. Diff/fransAx
N / A
7. PCV Valve
N / A
8. Breather.
N/A
_
9. P.S. Fluid
.. _. _ _ _
FULL
10. Brake Fluid.
FILLED
11. Chassis Tube
COMPLETE
12. Wiper Blades
CHECKED & OK -
13. Washer Fluid
FILLED
14. BatteryWater
.MAIN. FREE
15. Tire Press
CHECKED & OK
Vehicle Note (9/30/21): Oil I qt low on arrival.
Vehicle Note (9/30/21): Oil full after service. Drain plug and filter dry and tight.
Vehicle Note (9/30/21): front Jiff leaks
Vehicle Note (9/30/21): customer informed about possible gas leak
SubTotal $78.20
Net Labor Total $0.00
Discounted $0.00
NC (6.75%) $5.28
Total $83.48
Payment Applied
Visa $83.48
Any claims for faulty workmanship must first be presented to the store manager before any refunds and/or damage reimbursement will be honored. Do not
have any work performed on your vehicle without calling the store manager first if you expect reimbursement.
Customer Signature
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