53691_COOPER, AB_20090527

❑CAMA / El DREDGE & FILL L -(l4-11, ,
GENERAL PERMIT revious Permit #
LaWvw -]Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC J
❑ Rules attached. 3
Applicant Name Project Location: County
Address
City
State
ZIP
Phone # (.)'
Fax # ( )
Authorized Agent
ElCW
❑ EW 4 PTA ❑.ES
ElPTS
Affected
AEC(s): ❑ OEA
❑ HHF ❑ IH ❑ UBA
❑ N/A
PWS:
❑ FC:
ORW: yes / no
PNA yes / -rfio Crit.Hab. yes / no
Street Address/ State Road/ Lot #(s)
Subdivision
City------- ZIP------
Phone # ( ) River Basin
Adj. Wtr. Body - (nat /man/unkn
Closest Maj. Wtr. Body
Type of Project/ Activity
(Scale:
j
)
Pier (dock) length
Platfo
rm(s)
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
c�1169
Application Fee(s) Check #
Permit Officer's Signature
r
Issuing Date t Expiration:bate '
Local Planning Jurisdiction Roverfiile Nam

b
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 ❑ 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 Quality. Contact the Division of Water Quality at the Washington Regional Office (252-946-6481) or the Wilmington
Regional Office (910-796-7215) for more information on howto complywith these buffer rules.
Division of Coastal Management Offices
Raleigh Office Morehead City Headquarters
Mailing Address: 400 Commerce Ave
1638 Mail Service Center Morehead City, NC 28557
Raleigh, NC 27699-1638 252-808-2808/ 1-888-4RCOAST
Location: Fax: [phone]
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293
Fax:[phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico Counties)
Elizabeth City District
1367 U.S. 17 South
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 -below New River Inlet- and
Pender Counties)
Revised 08/09/06

�b.
NCDENR
North Carolina Department of Environment and Natural
Division of Coastal Management
Michael F. Easley, Governor James H. Gregson, Director
Date 3.6 -09
Name of Property Owner Applying for Permit:
Mailing Address:
William G. Ross Jr.
I certify that I have authorized (agent) to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date)
.4-.09
Property Owner Signature
Date
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled 11o% Post consumer Paper

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PI ER/MOORI NG PI LI NGS(BOATLI FT/BOATH OUSE)
�y V '
6
I hereby certify that I own property adjacent toS
(Name of Property Owner)
property I ocated at I O r,6 %y c)2d d V it i vG , ®�
(Lot, Block, Road, etc.)
I L.,► �9c , N.C.
on 4-- in
(Waterbody). (Town and/or County)
He has descri bed to me, as shown below, the devei opment he is proposing at that location,
arid, I have no obj ecti ons to his proposal. I understand that a pi er/mooring pi I i ngstboatl i ft/boathouse
must be set back a minimum distance of fifteen feet (16) from my area of riparian access unless
waived by me.
- I_ do -not wish-to-waive-thesetback requirement.
I do wish to waive that setback requi ren-att.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To befilled in by individual proposing development)
ppxdbE hrbd A ,
z Zo ­� e-
�� •
(Applicant Information)
�g
Mai I i ng Address
P . rp, )�' 2 ­5n
City/State/Zip
Telephone Number
•eFA�� a
(Riparian rroper vwuui iL�formation)
Signature
L C L J
Print or Type Name
Telephone Number
Date
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PI ER/MOORI NG PI LI NGS(BOATLI FT/BOATHOUSE)
4i lkgy
r19160
I hereby certify that I own property adjacent to `s�
(Name of Property Owner)
property located at oz4 h -5' M o m U^ If,-, G
,
(Lot, Block, Road, etc.)
�G l— L 9
on��—4 rL %��a9c � , N.C.
e So�� r� -� in
(Waterbody). (Town and/or County)
He has descri bed to me, as shown below, the devel opment he is proposing at that I ocati on,
and, I have no obj ecti onsto his proposal . I understand that a pi er/mooring pi l i ngstboatl i ft/boathouse
must be set back a minimum distance of fifteen feet (15') from my area of riparian aces unless
waived by me.
I do not wish to waive the setback requirement.
I do wi sh to wai ve that setback requi rement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To befiIIed in by individual proposing development)
R ur #� 11
2dx 2 2�O ��o�►L
��6 0 •
(Applicant Information)
Mailing Address
City/State0p
Telephone Number
-�•6-65'
Date
(Riparian Property Owner Information)
Sgnature
6>% c-Nx/
Pr nt or Type Name
Telephone Number
3/4-j o y'
De to
N

MR. ALFRED B. COOPER, JR. WACHOVIA BANK, NA 5680
BUSINESS ACCOUNT
P.O. BOX 250
ATLANTIC BEACH, NC 28512
6&21 /530 6/4/2009
PAY TO THE
ORDER OF NCDENR **800.00
Eight Hundred and
DOLLARS
Secunty features
cluded
NCDENR BDendiSe
Details on beck.
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