35226_THINSEN, DON_20031006

CAMA / ❑ DREDGE & FILL
GENERAL PERMIT
LlNew DModification ❑Complete Reissue ❑Partial Reissue
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
Previous permit f#
Date previous permit issued
Rules attached.
Applicant Name;), <; i Project Location: County_ -
Address ' 1 , „ , Street Address/ State Road/ Lot #(s) �y
City State -ZIP
Phone # Fax # ( ) Subdivision �..---
Authorized Agent i s City 4•-k&) V ;I<, ' ZIP , �' �' -•�J
Affected ❑ CW ❑ EW ElPTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑I HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑ FC:
ORW: yes / no PNA yes / no Crit. Hab. yes / no
Phone # ; River Basin ; I ( ►� f
Adj. Wtr. Body 1 (na�t /man /unkn)
Closest Maj. Wtr. Body
Type of Project/ Activity
(Scale: ' i
Pier (dock) length
Platform(s)__
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
✓ J j
ZA-
j 4
'
Basin, channel-
i
}
jjj f
cubic yards_
Boat ramp
G� .
Boathouse/ Boatlift
Beach Bulldozing
Other
Shoreline Length_
SAM not sure
yes no
Sandbags: not sure
yes no
Moratorium: n/a
yes no
Photos:
yes no
Waiver Attached:
yes no
A building permit may be required by: _
Notes/ Special Conditions
A/
Agent or Applicant Printed Name �!
Signature : Please read compliance se ssstaattement on back of permit
Application Fee(s) Check #
See note on back regarding River Basin rules.
i L
Permit Officer's Signature
Issuing Date j/ i Expiration Date
i�� �-S f A k w•.•..r.�s.......+w�,...rM
L(3EalPlanrfingJur� i�ion a Rover File Name

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 (910-395-3900) for more information on how to comply with thesebuffer rules.
Division of Coastal Management Offices
Central Office
Mailing Address:
1638 Mail Service Center
Raleigh, NC 27699-1638
Location:
Parker -Lincoln Building
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293 / 1-888ARCOAST
Fax:[phone]
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)
Morehead City District
151-B Hwy. 24
Hestron Plaza II
Morehead City, NC 28557
202-808-2808
Fax: [phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico 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
910-395-3900
Fax:[phone]
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
www.nccoastaimanagement.net
Revised 10/05/01

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CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual applying for Permit: TW;��--'
/✓
Address of Property: Zy� �s �•
(Lot or Strut ##, Street or Road, City & County)
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, should be provided with this
letter. A-1� I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coastal
Management, Hestron Plaza II, 151-B, Hwy. 24, Morehead City, NC, 28557 or call (252) 808-
2808 within 10 days of receipt of this notice. No response is considered the same as no objection
if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house, lift or sandbags must be
set back a minimum distance of 15' from my area of riparian access unless waived by me. (If you
wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
- ad , /0- -;, - 0?
Signa re Date
Print Name
2-51 -- 72-F- � Q
Telephone Number With Area Code

Adjacent Riparian Property Owner Statement
I hereby certify that I own property adjacent to,/
(name of Property Owner)
property located at
(Lot, Block, Road, etc.)
on , in x
(waterl;ody) (Town and/or County)
He has described to me as shown below, the development he is proposing at that
location, and I have no objections to his proposal.
Description and/or Drawing of proposed Development
(To be filled in by individual proposing development)
signatu
print or type name
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telephone number
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date

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