NPS SUP Application(Buxton) - Signed

NPS Form 10-930 (Rev. 08/2019)
National Park Service
OMB Control No. 1024-0026
Expiration Date 11/30/2023
"T0F'yF APPLICATION FOR PERMIT
FEES WAIVED
S Outer Banks Group
Cape Hatteras NS, Fort Raleigh NHS, Wright Brothers NMEM
H 3,' 1401 National Park Drive
Manteo, NC 27954 252-475-9034
E-Mail: caha special use Perm its(a-)nPs. gov
NATIONAL
PARK
SERVICE
A
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 do not require 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
[phone]
Email Address
Email Address
[e-mail]
Description of Proposed Activity (attach diagram and/or additional pages, if necessary)
The proposed project is to continue to protect NC Highway 12 and replenish sand losses due to
chronic erosion, hurricanes, and winter storms after the completion of the 2017-2018 beach
nourishment. It encompasses the same 15,500 linear feet of the oceanfront as the 2017-2018 project
including —2.2 miles in the Cape Hatteras National Seashore and —0.8 miles along the Village of
Buxton. It would be implemented using the same construction method (ie offshore dredging) and
would be completed within the same construction window (ie during summer months). Beach -quality
sand will be excavated from an offshore borrow area near Buxton Village via hydraulic or hopper
dredge, and up to 1,200,000 cubic yards of sand will be placed along the project area. The average
fill density is approximately 77 cubic yards per foot of shoreline, and the beach along the project area
will be widened by an average of —75 feet after natural profile adjustment. The proposed project will
also include a dune management plan along the Village of Buxton including dune construction, sand
fencing installation, and dune vegetation planting. The attached permit drawings and narrative
contain the details of the proposed project.
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, (N1-79-08-1)

NPS Form 10-930 (Rev. 08/2019)
National Park Service
OMB Control No. 1024-0026
Expiration Date 11/30/2023
Requested Location
Cape Hatteras National Seashore and the Village of Buxton
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. During the 2017 project, many crew members were able to park along NC 12 as well as in the Village of Buxton.
Ocean-going crew members will leave vehicles parked off site, likely in Wanchese or Oregon Inlet where crew boats will dock
(ie 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 [phone]
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 activity:
[phone]
Haiging Kaczkowski
Is this an exercise of First Amendment Rights? ❑ Yes X 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 ❑ 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? ® 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? ❑ Yes In 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 permit and associated records based on appropriate items) 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
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
David Clawson
Dare County Deputy Manager/Finance Director
Signature
Date
David Clawson Digitally signed by David Clawson
Date: 2021.05.26 10:06:00-04'00'
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 permits(a_nps.gov.
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 material 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 items) 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 item(s) in NPS
Records Schedule 1, Resources Management and Lands, (N1-79-08-1)