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Lewis, Carl
®,L]CAMA / ❑ DREDGE & FILL GENERAL PERMIT .New ❑Modification ❑Complete Reissue ❑Partial Reissue N9 78942 A B c' D Previous permit # Date previous permit issued As authorized by the State of North Carolina, Department of Environmental Quality ...... / and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC) 0 Rules attached. Applicant Name I Project Location: County Address rj ( yn Street Address/ State Road/ Lot #(s) City J�,i�V`� State ZIP Phone # 1 ( ) E-Mail Subdivision Authorized Agent J7 11,I "i i CityZIP -'NCW -SEW-E�]PTA ❑ES ❑PTS Phone# ( ) River Basin/::�/I��F Affected 0 OEA ❑ HHF ❑ IH ❑ UBA ❑ WA AEC(s): El PWS: Adj. Wtr. Body naf man unkn 1 - ORW: yes / no PNA yes / no Closest Maj. Wtr. Body Type of Project/Activity�- (Scale: ) Pier(dock)length ` - Fixed Platform �', ,$) �i.. Floating Platform(s) T Finger pier(s)I Groin length number Bulkhead/ Riprap length _ - avgdistance offshore' max distance offshore Basin, channel cubic yards -I h Boat ramp i _ _ Boathouse/ Boatlift I r. -� ,{ - I t I Beach Bulldozing Other. Shoreline Length ` ("n' j j I li SAV: not sure yes no Moratorium: n/a yes noPhotos: rF�H.111 yes no IWaiver Attached: yes no i A building permit may be required by: ❑ See note on back regarding River Basin rules. ( Note Local Planning jurisdiction) Notes/ Special Conditions Agent or Applicant Printed Name Signature ** Please read compliance statement on back of permit** Application Fee(s) Check# Permit Officer's Printed Name Signature Issuing Date Expiration Date 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 th is project is consistent with the North Carolina Coastal Management Program. River Basin Rules Applicable To Your Project: ❑ Tar- Pamlico River Basin Buffer Rules ❑ Neuse River Basin Buffer Rules ❑ Other: 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 Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-6481) or the Wilmington Regional Office (910-796-72 15) for more information on how to comply with these buffer rules. Division of Coastal Management Offices Morehead City Headquarters 400 Commerce Ave Morehead City, NC 28557 252-808-2808/ 1-8884RCOAST Fax: 252-247-3330 (Serves: Carteret, Craven, Onslow - North of New River Inlet- and Pamlico Counties) Elizabeth City District 401 S. Griffin St. Ste. 300 Elizabeth City, NC 27909 252-264-3901 Fax:252-264-3723 (Serves: Camden, Chowan, Currituck, Dare, Gates, Pasquotank and Perquimans Counties) Washington District 943 Washington Square Mall Washington, NC 27889 252-946-6481 Fax: 252-948-0478 (Serves: Beaufort, Bertie, Hertford, Hyde, Tyrrell and Washington Counties) Wilmington District 127 Cardinal Drive Ext. Wilmington, NC 28405-3845 910-796-7215 Fax:910-395-3964 (Serves: Brunswick, New Hanover, Onslow - South of New River Inlet - and Pender Counties) http://portal.ncdenr.org/web/cm/dcm-home Revised 7/06/17 AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS Name of Property Owner Applying for Permit: �a L' I LP.w i Mailing address: a 3� S n O r—e L a d Telephone Number: C� ( q 1_ a 2_ 3 2</ 9 I certify that I have authorized dl J t f S 1 i (agent/contractor), to act on my behalf, for the purpose of applying and obtaining all CAMA permits the proposed development of <� c' 1 ri < _ 19 �b \ r n S S at my property located at ), 3 15 k0r--e 1�00' V This certification is valid through (Property Owner Information) Signature Print or Type Name 6ar1 L L6Ljl 5 Title, co. owner or trustee for property - 20zc� Date Cg►I)-.aa-3a�� (date). Telephone Number ►'mar-�are,�le�,i5 23�f 4nyah�d,c,or� Email Address ail ADJACENT RIPARIAN PROPERTY.OWNER STATEMENT I hereby certify that I own property adjacent to C. or j L, L a, � 5 's (N a of Property Owner) property located at 3� S�tol j2c�Q ,�� // (Address, Lot, I ck, Road etc) on V j � �1 u ei'r in � V0FV N.C. (Waterbody) (Ci /Town and/or County) The applicant has described to me, as shown below, the development proposed at the above location 7 1 have no objection to this proposal. I have objections to this proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (Individual proposing development must fill in description below or attach a site drawing) kV r ;5 be.5e_7�- rrl�u+,\ J {--w\\� 0 O O C� © O O U (!D C) 0 © n c-; I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin 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. (Property Owner Information) (Adjacent Property Own Information) ay_X,y,..t.w V ern � Signature S�igq ure Print or Type Name Print or Typ Name a3X Skore Laj aL-,� Saxe_ �flQAa Mailing Address 231 Shore. Q®ad cifyv,statelzip Telephone umber (611a I �L 3)L-`Oi Date 611812012) Mekk Mailing Address ,, I I ewQ,(+ n57o City/State/Zip I Telephone umber (ZS 2 2yv-�9q5 Date (Revised ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I hereby certify that I own property adjacent to C,oc- \ L . \-aw� 5 s X)n h�(e_. (2,0 acne of Property Owner) property located at lC�� \ Address, Lot, Ell pk, Road, etc.) on OC,000A— (�t \) , in �.1 e-'i orgy , N.C. (Waterbody) and/or County) The applicant has described to me, as shown below, the development proposed at the above location. i I have no objection to this proposal. I have objections to this proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (Individual proposing development must fill in description below or attach a site drawing) i I rls S �,.i �'p £. G� M . it •/�, •., van. ��, \ k- : )C Cl� i Il ( D 0 D NLw 7i i� nJo S 'A WAIVER SECTION 1 understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin 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. J I do not wish to waive the 15' setback requirement. (Property Owner Information) (Adjacent Property Owner Information) Signature Signature earI L Le,1.01s -"h",r.,r..a's Print or Type Name Print or Type Name Mailing Address 236 51, ' 4- City/State/Z/p t&,, p c: - kf G 2�57c� Mailing Address 22-9 14 City/State ,p 1VewQur NLr2S' 70 61 Telephone Number (AI zza-3a�� Date Telephone Number (;Z�5 �) �&Dg Date 6/18/2012) (Revised