NPS SUP Application(Avon-Dare County) - Signed

NPS Form 10-930 (Rev. 08/2019)
National Park Service
APPLICATION FOR PERMIT
k FEES WAIVED
y8 Outer Banks Group
•'' • Cape Hatteras INS, Fort Raleigh NHS, Wright Brothers NMEM
°"�" ��•* 1401 National Park Drive
Manteo, NC 27954 252-475-9034
E-Mail: caha special use oermits0noa.00v
OMB Control No. 1024-0026
Expiration Date 11/302023
Please supply the information requested below. Attach additional sheets, if necessary, to provide required information. A
nonrefundable processing fee of $N/A must accompany this application unless the requested use is an exercise of a First Amendment
right. You must allow sufficient time for the park to process your request; check with the park for guidelines. You will be notified of the
status of the application and the necessary steps to secure your final permit. Your permit may require the payment of cost recovery
charges and proof of liability insurance naming the United States of America an additional insured.
* Enter either a Social Security Number OR a tax ID number we de not reerrlra both
Applicant Name
Company/Organization Name
Robert Outten
Dare County
Social Security Number*
Tax Identification Number*
N/A
N/A
Street Address
Street Address
954 Marshall Collins Drive
City
State
Zip Code
Country
City
State
Zip Code
Country
Manteo
NC
27954
USA
Telephone Number
Contact Name
[phone]
Cell Phone Number
Telephone Number
Fax Number
Fax Number
(252) 473A817
Email Address
Email Address
[e-mail]
Description of Proposed Activity(attach diagram and/or additional pages, if necessary)
The proposed Avon Village beach nourishment is to restore the critically eroded oceanfront south of
the Avon Pier along with its immediate upcoast area. It is to protect NC Highway 12 from future
flooding and overwash and replenish sand losses due to chronic erosion. The proposed project
encompasses 13,200 linear feet (2.5 miles) of the Cape Hatteras National Seashore in front of the
Avon Village, Dare County, as the Applicant and Project Sponsor, proposes to place 1 million cubic
yards of beach -quality sand along the shoreline from about 4,000 feet north of the Avon Pier at Due
East Road to the southern boundary of Avon. The average fill density will be 75 cubic yards per foot
of shoreline, and the beach will be widened by an average of 75 feet after natural profile adjustment.
Nourishment sand will be excavated from an offshore borrow area via hydraulic or hopper dredge(s),
and the proposed cut depth is 6A0 ft below the existing substrate. A dune management plan (ie -
initial dune construction, sand fencing installation, and dune vegetation planting) will be included in
the proposed project to enhance the storm protection for the project area. The proposed
nourishment is in compliance with NPS' Cape Hatteras National Seashore Sediment Management
Framework, and the construction window targets summer 2022. More details are included in the
enclosed Narrative and Permit Drawings,
Page 1 of 4
RECORDS RETENTION: Unapproved (3 years). Maintain Approved applications with related permit and associated records based on appropriate items) in NPS
Records Schedule 1, Resources Management and Lands, (NI-79-OS-1)

NPS Form 10-930 (Rev. 082019)
National Park Service
OMB Control No. 1024-0026
Expiration Date 11/302023
Requested Location
Cape Hatteras National Seashore in front of the Village of Avon
Set -Up Begins
Activity Begins
Activity Ends
Removal Completed
Date 1 May 2022
Date 15 May 2022
Date 30 Sept 2022
Date 30 Sept 2022
Time ❑ AM ❑ PM
Time ❑ AM ❑ PM
Time ❑ AM ❑ PM
Time ❑ AM ❑ PM
Date
Date
Date
Date
Time ❑ AM ❑ PM
Time ❑ AM ❑ PM
Time ❑ AM ❑ PM
Time ❑ AM ❑ PM
Date
Date
Date
Date
Time ❑ AM ❑ PM
Time ❑ AM ❑ PM
Time ❑ AM ❑ PM
Time ❑ AM ❑ PM
Maximum Number of
Maximum Number of Vehicles (attach parking plan)
Participants (Best Estimate)
70
Cars Vans/Light Trucks Utility Vans/Trucks Buses/Oversized Vehicles
30 10 5-10 2
Support equipment (list all equipment; attach additional pages if necessary)
Sand placement and grading equipment including bulldozers, front end loaders, and trucks on the beach.
Operation will likely feature 4-5 dozers and/or loaders on the beach at a given time, along with 3-5 trucks
moving equipment and material from the staging area to the work zone. In the ocean, an ocean -certified
dredge along with 2-3 tugs will be present within the borrow area (-2-3 miles from the project site). During
set up and removal of equipment, tugs and transport barges may approach closer to shore in order to
place/remove material from the beach itself. Parking for beach crew members will be designated following
consultation between Dare County, NPS, NCDOT, and the contractor. Ocean-going crew members will leave
vehicles parked off site, likely in Wanchese or Oregon Inlet where crew boats will dock lie off NPS property).
List support personnel including addresses and telephones; attach additional pages if necessary
Name Address Cell Phone Number
Tim Kana, Project Director 160 Gills Creek Pkwy Columbia SC 29202 (803) 361=3583
Haiqing Kaczkowski, Project 160 Gills Creek Pkwy Columbia SC 29202 [phone]
Engineer
Patrick Barrineau, Asst, Project 160 Gills Creek Pkwy Columbia SC 29202 [phone]
Manager
Individual in charge of activity onsite who is authorized to make decisions related to the
Cell Phone Number
permitted aotiz
Haigiaiging Kaczkowski
[phone]
Is this an exercise of First Amendment Rights? ❑ Yes K No
Have you visited the requested area? © Yes ❑ No
Have you obtained a permit from the National Park Service in the past? (see attached narrative) ®Yes [I No
(If yes, provide a list of permit dates and locations on a separate page.)
Do you plan to advertise or issue a press release before the event? IRJ Yes ❑ No
Will you distribute printed material? ® Yes ❑ No
Is there any reason to believe there will be attempts to disrupt, protest or prevent your event? El Yes ( No
(If yes, please explain on a separate page.)
Do you intend to solicit donations or offer items for sale? (These activities may require an additional permit.) ❑ Yes ® No
Is this permit to carry out a Good Samaritan Search and Recovery Mission? ❑ Yes ® No
Page 2 of 4
RECORDS RETENTION: Unapproved (3 years). Maintain Approved applications with related penni[ and associated records based on appropriate items) in NPS
Records Schedule 1, Resources Management and Lands, (NI-79-08-1)

NPS Form 10-930 (Rev. 082019)
National Park Service
OMB Control No. 1024-0026
Expiration Date 11/30/2023
You are encouraged to attach additional pages with information
useful in evaluating your permit request including: staging,
sound systems, parking plan, security plans, sanitary facilities, crowd
control, emergency medical plan, use of any building, site clean-
up, etc.
The applicant by his or her signature certifies that all the information given is complete and correct, and that no false or misleading
information or statements have been given.
Printed Name
Title
Robert Oyftn
Dare County Manager/Attorney
Signature
Date
1&4��
NOTICES
IMPORTANT NOTICE TO APPLICANT
This is an application only and does not serve as permission to conduct any special activity in the park. The information provided will
be used to determine whether a permit will be issued. Send the completed application to caha special use permits0nps.pov.
If your request is approved, a permit containing applicable terms and conditions will be sent you. The permit must be signed by the
responsible person and returned to the park for final approval by the Park Superintendent before the permitted activity may begin.
Privacy Act Statement
General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals
completing this application.
Authority: The authority to collect information on the attached form is derived from 54 U.S.C. 100101, Promotion and regulation; 54
U.S.C. 100751(a), Regulations; 54 U.S.C. 103104, Recovery of costs associated with special use permits; and 54 U.S.0 Commercial
Filming.
Purposes and Uses: The information being collected to allow the park manager to make a value judgment on whether or not to allow
the requested use. Information from the application may be transferred to appropriate Federal, State, and local agencies, when
relevant to civil, criminal or regulatory investigations or prosecutions.
Effects of Nondisclosure: It is in your best interest to answer all of the questions. The U.S. Criminal Code, Title 18 U.S.C. 1001,
provides that knowingly falsifying or concealing a matedal fact is a felony that may result in fines of up to $10,000 or 5 years in prison,
or both. Deliberately and materially making false or fraudulent statements on this form will be grounds for not granting you a Special
Use Permit
Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579
Section 7(b):
Your Social Security
Number (SSN) is needed to identify records
unique to you. Applicants are required to provide their
social security
or taxpayer
identification number for activities subject to
collection of fees and charges by the National Park Service. Failure to disclose your SSN
may prevent or delay the processing of your
application. The authority for soliciting your SSN is 54
U.S.C.103104.
The information
gathered through the use of the SSN will
be
used only as necessary for processing this application
and collecting
and reporting any
delinquent financial obligations. Use of the social security number will be carried out in accordance
with established regulations and
published notices of system of records.
Paperwork Reduction Act Statement
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the park managers the
information needed to decide whether or not to allow the requested use. All applicable parts of the form must be completed in order for
your request to be considered. You are not required to respond to this or any other Federal agency -sponsored information collection
unless it displays a currently valid OMB control number.
Estimated Burden Statement
Public reporting burden for this form is estimated to average 30 minutes per response including the time it takes to read, gather and
maintain data, review instructions and complete the form. Direct comments regarding this burden estimate, or any aspects of this form,
to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Drive Reston, Virginia 20192. Please do
not send your form to this address.
INTERNAL AGENCY USE ONLY
Page 3 of 4
RECORDS RETENTION: Unapproved (3 years). Maintain Approved applications with related permit and associated records based on appropriate i[em(s) in NPS
Records Schedule 1, Resources Management and lands, (N1-79-08-1)

NPS Form 10-930 (Rev. 08/2019)
National Park Service
OMB Control No. 1024-0026
Expiration Date 11/30/2023
Project Number/BILL
Date Processed
Permit Number
Prepared By
Organization Name
Page 4 of 4
RECORDS RETENTION: Unapproved (3 years). Maintain Approved applications with related permit and associated records based on appropriate items) in NPS
Records Schedule I, Resources Management and Lands, (N1-79-08-I)