38019_General Permit_20040325

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„ CAMA / ❑ DREDGE & FILL
GENERAL PERMIT
Previous permit #
❑New ❑Modification ❑IComplete 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
❑ Rules attached.
Applicant Name__
Address
City
Phone # (�)
Authorized Agent
CW
Affected E oEA
AEC(s):
11 PWS:
ORW: yes / no
State
Fax # O
r. EW _] PTA
_I HHF = IH
C' FC:
PNA yes / no
ZIP
ES C PTS
[- UBA - I N/A
Crit. Hab. yes / no
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision
City -
Phone # ( )
Adj. Wtr. Body
Closest Maj. Wtr. Body
ZIP_
River Basin
(nat /man /unkn)
Type of Project/ Activity
(Scale: ;, )
Pier (dock) length_ f I
Platform(s)
Finger pier(s) ` I
Groin length
number
Bulkhead/ Riprap length
avg distance offsho r -
max distance offshore J
Basin, channel re
cubic yards
Boat ramp
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
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See
note
on
back
regarding
River
Basin
rules.
Agent or Applicant Printed Name
Permit Officer's Signature
Signature ** Please read compliance statement on back of permit ** Issuing Date
Application Fee(s)
Check# Local PlanningJurisdiction
Expiration Date
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 [)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 Eliasin 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

DAVID F. WINBERRY 6PC-3 Oai
SARAH R. WINBERRY
PH. 252-393-2281 NCDL 3277007
1006 CEDAR POINT BLVD.
SWANSBORO, NC 285M
Pay to the D p— � R,
Order of
GUI
BankofAmerica®
�I..0 Bank of America Advantage®
ACH WT 053000'9
For
1:0530001961: 0006361-60sC, 37L,0
3740
66-19/5 �� - 30 NC
Date 2002
s I46. o(--
()o I I a r s 8 m„
GUARDIAND SAFETY BLUE DEBL

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS/BOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to 's
/ fV'amo- ni Iro Aty Owner)
property located at ,,�IQ F
(Lot., Block, Road, etc.)
9
on , in c� �� , N.C.
(NVaterbody) (Town and/or County)
Y
He has described to me, as shown below, the development he is proposing at that location,
and, I have no objections to his proposal. I understand that a pier/mooring
pilings/boatlift/boathouse must be set back a minimum distance of fifteen feet (15') from my area
of riparian access unless waived by me.
I do not wish to waive the setback requirement.
I dQ wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPi`IENT:
(To be filled in by individual proposing developent)
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gignawre cv
Print or Type/Name
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Telephone Number
Date: �; ^0702— 6)3

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFTIBOATHOUSE)
I hereby certify that I own property adjacent to
lNam� of Pro rty Owner)
Property at located 6 � _ '
'
(Lot, Block, Road, etc.)
on
in �&-�*
( aterbotly) (Town acid/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. I understand that a pier/mooring
pilings/boatlift/boathouse must be set back a minimum distance of fifteen, feet (15') from my area
of riparian access unless waived by me.
I .d j1Qt wish to waive the setback requirement.
I dg wish to waive that setback requireme � p
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DESCRIPTION AND/OR DRAWING OFOMSED DEVELOPMENT: Q
(To „be filled in by individual psin$ development)_ t Q y¢
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Print or Type Name
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Telephone Nu. ber
Date:�9163
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