20230519 Ver 1_CAMA Application_20230414 (2)

PROJECT NARRATIVE
Smith Property
March 20, 2023
Project Description:
RECEIVED
DCM-EC',",'
The subject property is located at 47047 Rocky Rollinson Road, Buxton, Dare County,
North Carolina. The property is an,8.48 acre parcel which consists of 1.72 acres of
uplands, a single family residence with a separate accessory dwelling unit
(residence/garage) to the west of the main house. Additional improvements include the
existing pier, platform, and 50 linear feet of rock rip -rap along the shoreline of the
existing basin.
The proposed improvements to the property include the installation of a 15' x 20'
concrete boat ramp and gravel drive to access boat ramp from existing gravel driveway.
The owner intends to use the existing grade of the bank and install the concrete on the
existing slope without excavation. The access drive to the proposed ramp will be
constructed of #57 stone with geotextile fabric and will not contribute to the impervious
areas within the property. A 15' section of rock rip -rap will be removed for the
installation of the boat ramp and will impact 105-120 square feet of Coastal Wetlands
(Spartina patens) located along the shoreline. There is adequate water depth for the
boat ramp and no excavation is proposed for the project. The concrete ramp will be
poured on the upland area and allowed to cure prior to moving into place. 440 feet of
additional rock rip -rap revetment will be installed along the shoreline to prevent further
erosion of the existing coastal wetlands.
Existing Site Area: 369,431 sf (8.48 acres)
Existing Areas in 76'AEC: 78,685 sf
ImDervious Areas in 76' AEC:
Existing house ........ ....................... ........ 1,840 sf
Existinggravel drive ...................... 2,742 sf
Total = 4,682 sf
Percent Impervious: 4,582/78,685 = 6%
Existing Impervious Areas on the Prope
House................. ____ ....... _ .......................... ___ ........ 1,840 sf
Garage/Residence ........... __ ......... ...... .......................... 1,228 sf
Gravel Drive ............................................ ......... ........ 5,543 sf
Total = 8,611 sf
Percent Impervious: 8,681/74,808 = 11.6%
Proposed Land disturbance:
Land disturbance limited to new gravel access drive to boat ramp = 400 sf

Section 404 and Coastal Wetlands:
The 404 wetlands were delineated by Atlantic Environmental Consultants, LLC
September 2022 and the coastal wetlands were delineated by Yvonne Carver
with the NC Division of Coastal Management on February 28, 2021105-120
square feet of Coastal Wetlands(Spartina patens) will be impacted by the
installation of the boat ramp.
Submerged Aquatic Vegetation(SAVI:
A recent site visit on February 14, 2023 found there was no SAV present in the
proposed work area. Water depths in the project area range from -1.0' to -3.5'
and no dredging is proposed for the proposed boat ramp,
Stormwater:
Upland development to include the additional gravel access drive (400sf) to the
new boat ramp. The access drive to the proposed boat ramp will be constructed
of #57 stone with geotextile fabric and will not contribute to the impervious areas
within the property.
Sedimentation Erosion Control Plan:
Silt fence will be installed along the access driveway work area to prevent sediment
runoff to adjacent waters.
The project proponent hereby certifies that all information contained herein
is true, accurate, and complete to the best of my knowledge and belief.
• The project proponent hereby requests that the certifying authority review
and take action on this CWA 401 certification request withiin the applicable
reasonable period of time.

DIVISION OF COASTAL MANAGEMENT
FIELD INVESTIGATION REPORT
APPLICANT'S NAME: John and Sherry Smith
2. LOCATION OF PROJECT SITE: 47047 Rocky Rollinson Road (SR 1230), Buxton,
Dare County; Adjacent man-made basin which connects to Cape Creek and the
Pamlico Sound
Latitude: 350 16' 8.73" N Longitude: 750 311'30,116" W
3. INVESTIGATION TYPE: LAMA, D&F
4, INVESTIGATIVE PROCEDURE: Dates of Site Visit— 01/19/23; 02/28/23
Was Applicant Present — Yes
5. PROCESSING PROCEDURE: Application Received Complete — 04/10/23
Office - Elizabeth City
6. SITE DESCRIPTION:
(A) Local Land Use Plan — Dare County
Land Classification From LUP — R-2A — Alternative Medium Density Residential
(B) AEC(s) Involved: Coastal Shoreline (CS), Coastal Wetlands (CW), Estuarine
Waters (EW) and Public Trust Area (PTS)
(C) Water Dependent: Yes
(D) Intended Use: Private
(E) Wastewater Treatment: Existing — Septic System
Planned - None
(F) Type of Structures-, Existing — Houses/garage, pier, walkway,
Platform, rock riprap
Planned - Boat ramp & rock riprap revetment
(G) Estimated Annual Rate of Erosion: 1-2'
Source— Applicant & site observation
7. HABITAT DESCRIPTION: [AREA]
DREDGED FILLED OTHER
(A) Vegetated Coastal Wetlands
±120 sf
(B) Open Water / Shallow Bottom
300 sf (ramp)
2,,640 sf (riprap)
Other (high ground)
±400 sf gravel
access
(D)
Total Area Disturbed:
(E)
Primary Nursery Area
(F)
Water Classification:
3,460 sf (0.08 acres)
No
SA; HQW Open: Closed to shellfishing
8. PROJECT SUMMARY: Applicant is proposing the installation of a 20'x15'concrete
boat ramp with a gravel drive access, and the installation of a rock riprap revetment.

Field Investigation Report - John and Sherry Smith
Page 2
Project Setting
The development site is located at 47047 Rocky Rollinson Road in Buxton, Dare County, in
an adjacent man-made basin which connects to Cape Creek and the Pamlico Sound, The
8.48-acre parcel, which is approximately 5' above normal water level (NWL), is currently
developed with 2 single-family residences (one with, an elevated ramp to a garage),
associated decking and gravel driveways. The existing water -dependent structures in the
basin include a pier with platforms and ±50 linear feet (Ift) of rock riprap adjacent to a
section of coastal wetlands. The parcel is noted to be 1.72 acres of upland and 6.76 acres
of Coastal Wetlands (CW) and non -coastal vegetation. This vegetation includes Black
Needlerush (Juncus roemerianus), Salt Meadow Hay (Spartina patens) Smooth cordgrass
(Spartina alterniflora), pine, oak and red maple trees, and Atlantic red cedar.
The adjacent riparian property is developed with a single-family residence, swimming pool,
and pier to the northwest and vacant, coastal marshland to the east.
Previous permitting! for the project site consisted of a general permit (GP) issued in 1999 to
Otis Willlis for a boat ramp adjacent a pier, platform and walkway, and a GP issued to the
current owner in 2017 for a replacement pier and platform and the installation of a riprap
revetment for wetland protection, and shoreline erosion control. It is noted that although 450
Ift of riprap was authorized, only a small section was installed along the shoreline near the
pier. The applicants obtained a new GP in March 2023 for a separate pier, platform and
boatlift.
The waters of Cape Creek and Pamlico Sound are Coastal Waters in the Pasq,uotank River
Basin and are classified as SA and HQW. These waters are not in a primary nursery area
but are closed to shellfish taking. The water depths in the project area range from -2.0 to
-4,0,
Development Proposal
Mr. and Mrs. Smith propose to remove a 15-foot section of rock riprap and install a 20'x1 5'
concrete boat ramp on the left (northwest) side of the current pier, with 400 square feet (sf)
of gravel access. The concrete for the ramp will be poured on an upland area and will not
be installed until after it is cured. The location of the proposed boat ramp will impact ±120 sf
of CW vegetation that consists of Salt Meadow Hay (Spartina patens). The boat ramp will
provide water access for a personal power boat and kayaks. The closest public boat ramp
is located in northern Rodanthe. The applicants also propose the installation of ±440 Ift of
rock riprap, with a maximum width of 6 feet, as a revetment for wetland protection and
erosion control along the western shoreline of the basin,.

Field Investigation Report- John and Sherry► Smith
Page 3
Anticipated Impacts = 3,6400 sf
The installation of the boat ramp and associated gravel access will fill ±1 20 sf of CW AEC.
The installation of the concrete boat ramp below NWL and riprap revetment will impact
2,940 sf Shallow Bottom Habitat of the EMPTA AECs.
The installation of the gravel access drive will disturb ±400 sf of Coastal Shoreline AEC.
Submitted by: Yvonne Carver
Date: 04/11/23

Dom MP-1
APPLICU10111 for
major Development Permit
(last revised 12127/06)
North Carolina DIVISION OF COASTAL MANAGEMENT
1. Primary Applicant/ Landowner Information
Business Name
Project Name (if applicable)
Smith boat ramp
Applicant 1: First Name
MI
Last Name
John
Smith
Applicant 2: First Name MI
Last Name
Sherry
Smith
If additional applicants, please attach an additional page(s) with flames listed.
Mailing Address
PO Box
City
State
33576 S Main Street
Townville
PA
ZIP Country Phone No.
FAX No.
16360 USA 814 - 671
- 0601 ext.
Street Address (if different from above)
I
city State ZIP
-
Email
.. .... . — --------
johnsmith_1 [e-mail]
2. AgentlContractor Information
Business Name
Atlantic Environmental Consultants, LIc
Agent/ Contractor 1: First Name
MI
Last Name
Doug
A
Dorman
Agent/ Contractor 2: First Name
MI Last Name
Mailing Address
PO Box City
State
P.O. Box 3266 Kitty Hawk
NC
ZIP
Phone No. 1 Phone No.
2
27949
252.599 - 2603 ext.
ext.
FAX No.
Contractor #
Street Address (if different from above)
City State
ZIP
.... ......
Email
[e-mail]
<Form continues on back>
r; (1), /3", F1 (
"F , �2

Form DCM MP-1 (Page 2 of 4)
�iECIlk
,EIVED APPLICATION for
MAR 2 2 2023 Major Development Permit
3. Project Location
County (can be multiple) Street Address State Rd. #
Dare 47047 Rocky Rollinson Road 1230
Subdivision Name
City
State
Zip
None
Buxton
NC
27920-
Phone No.
Lot No.(s) (if many, attach additional page with list)
814 — 671 - 0601 ext.
N/A,
a In which NC river basin is the project located?
b. Name of body of water nearest to proposed project
Cape Creek
ca. Is the water body identified in (b) above, natural or manmade?
d. Name the closest major water body to the proposed project site.
ENatural EDManmade E]Unknown
Parnifico Sound
e , Is proposed work within city limits or planning jurisdiction?
f. If applicable, list the planning jurisdiction or city limit the proposed
EYes 0No
work falls within.
Dare County
4.
Site Description
a.
Total length of shoreline on the tract (ft.)
b. Size of entire tract (sq.ft.)
2713 Ft.
369,431 sq.ft.
c.
Size of individual lot(s) d. Approximate elevation of tract above NHW (normal high water) or
369,431 sq.ft., NWL (normal water level)
(If many lot sizes, please attach additional page with a list) 5' EINHW or SNWL
a.
Vegetation on tract
Pine trees, Oak trees, Red Maple trees, Red Cedar, Wax myrtle, Black Needle Rush, Spartina sp. .
f.
Man-made features and uses now on tract
- House & garages
- 50' rock rip -rap shoreline
- 4'x10' pier
- 4'xTwalkway
- 260 sq.ft. platform
g.
Identify and describe the existing land uses adiacen to the proposed project site.
The existing land use adjacent to the property are residential.
h.
How does local government zone the tract?
i. Is the proposed project consistent with the applicable zoning?
R-2A- Alternative Medium Density Residential District
(Attach zoning compliance certificate, if applicable)
®Yes E]No EINA
j.
Is the proposed activity part of an urban waterfront redevelopment proposal? E]Yes ®No
k.
Hasa professional archaeological assessment been done for the tract? If yes, attach a copy. E]Yes NNo EINA
If yes, by whom?
I.
Is the proposed project located in a National Registered Historic District or does it involve a []Yes ZNo EINA
National Register listed or eligible property?
------ . ..... .....
<Form continues on next page>

Form DCM MP-1 (Page 3 of 4) APPLICATION for
Major Development Permit
- ---------- . . ......
M. (i) Are there wetlands on the site?
NYes E]No
(ii) Are there coastal wetlands on the site?
E]Yes E]No
(iii) If yes to either (i) or (!I) above, has a delineation been conducted?
HYes ®No
(Attach documentation, if available)
n. Describe existing wastewater treatment facilities.
Existing conventional septic system,
E C, E I E
o. Describe existing drinking water supply source.
2
2 2023
Dare County public water supply.
p. Describe existing storm water management or treatment systems,
DCM-EC
None.
5. Activities and Impacts
a. Will the project be for commercial, public, or private use? E]Commercial OPublic/Government
EPrivate/Community
b, Give a brief description of purpose, use, and daily operations of the project when complete.
The purpose of the project is to install a 15' x 20' concrete boat ramp adjacent to the existing dock. 440 feet of additional
rock rip -rap revetment will be added along the shoreline. Daily use of the boat ramp and dock is for boat and kayak access
to the adjacent waters of the Pamilico Sound.
c. Describe the proposed construction methodology, types of construction equipment to be used during construction, the number of each type
of equipment and where it is to be stored.
The existing rock rip -rap will be removed in the location of the proposed boat ramp. The concrete will, -ramp will be poured on
near upland location and pushed into place once the concrete has cured. 440 feet of additional rock rip -rap revetment will be
installed along the shoreline to protect the eisting wetlands. Additionl gravel will be extended from the existing drive to the ne
—boat ramp location,
d. List all development activities you propose.
1. Install 15' wide x 20' long boat ramp,
2. Install gravel drive to boat ramp.
3. 440 feet rock rip -rap revetment
e. Are the proposed activities maintenance of an existing project, new work, or both? New
f. What is the approximate total disturbed land area resulting from the proposed project? 400 ESq.Ft or nAcres
g. Will the proposed project encroach on any public easement, public accessway or other area EEJ]Yes EINo EINA
that the public has established use of?
h. Describe location and type of existing and proposed discharges to waters of the state.
There are currently no discharges to waters of the state. The proposed improvements will not have discharge to waters of
the state.
L Will wastewater or stormwater be discharged into a wetland? E]Yes ENo EINA
If yes, will this discharged water be of the same salinity as the receiving water? E]Yes []No UNA
j. Is there any mitigation proposed? E]Yes ENo FINA
If yes, attach a mitigation proposal.
<Form continues on back>

Form DCM MP-1 (Page 4 of 4)
APPLICATION for
Major Development Permit
6. Additional Information
in addition to this completed application form, (MP-1) the following items below, if applicable, must be submitted in order for the application
package to be complete. Items (a) — (0 are always applicable to any major development application. Please consult the application
Instruction booklet on how to properly prepare the required items below.
a. A project narrative.
b. An accurate, dated work plat (including plan view and cross -sectional drawings) drawn to scale. Please give the present status of the
proposed project. Is any portion already complete? If previously authorized work, clearly indicate on maps, plats, drawings to distinguish
between work completed and proposed.
c. A site or location map that is sufficiently detailed to guide agency personnel unfamiliar with the area to the site.
d. A copy of the deed (with state application only) or other instrument under which the applicant claims title to the affected properties.
e. The appropriate application fee. Check or money order made payable to DENR.
f. A list of the names and complete addresses of the adjacent waterfront (riparian) landowners and signed return receipts as proof that such
owners have received a copy of the application and plats by certified mail. Such landowners must be advised that they have 30 days in
which to submit comments on the proposed project to the Division of Coastal Management.
Name Chalres Pereira Phone No. None
Address 1008 Megson Court, Raleigh, NC 27614
Name Phone No.
Address
Name Phone No.
Address
g. A list of previous state or federal permits issued for work on the project tract. Include permit numbers, permittee, and issuing dates.
GPA21320 issued to Otis Willis on 02/08/19 -J GPA69954 issued to John 0. Smith on 0312412017
h. Signed consultant or agent authorization form, if applicable.
1. Wetland delineation, if necessary.
j. A signed AEC hazard notice for projects in oceanfront and inlet areas. (Must be signed by property owner)
k. A statement of compliance with the N.C. Environmental Policy Act (N.C.G.S. 113A 1-10). if necessary. If the project involves expenditure
of public funds or use of public lands, attach a statement documenting compliance with the North Carolina Environmental Policy Act.
1 7. Certification and Permission to Enter on Land I
I understand that any permit issued in response to this application will allow only the development described in the application.
The project will be subject to the conditions and restrictions contained in the permit.
I certify that I am authorized to grant, and do in fact grant permission to representatives of state and federal review agencies to
enter on the aforementioned lands in connection with evaluating information related to this permit application and follow-up
monitoring of the project,
I further certify that the information provided in this application is truthful to the best of my knowledge.
Date 03/20/23
Print Name —Doug Dorman, Consultant
Signature
Please indicate application attachments pertaining to your proposed project.
EIDGM MP-2 Excavation and Fill Information E]DCM MP-5 Bridges and Culverts
[ADCM MP-3 Upland Development
EIDCM MP-4 Structures Information
RECEIVED
MAR 2 2 2023
DCM-EC
t < t "Y", `!" V11 I

jm=r �
14 kq 111�­­I���' 1
d 101 z 11111111111 '91 R
(Except for bridges and culverts)
Attach this form to Joint Application for LAMA Major Permit, Form DGM MP-1. Be sure to complete all other sections of the Joint
Application that relate to this proposed project. Please include all supplemental information.
Describe below the purpose of proposed excavation and/or fill activities. All values should be given in feet.
Access
Channel
(NLW or
NWL)
Canal
Boat Basin
Boat Ramp
Rock Groin
Rock
Breakwater
Other
(excluding
shoreliine
stabilization)
Length
20'
Width
15'
Avg. Existing
. . .
... . .... .
S
NA
NA
Depth
Final Project
. .... ------
3.5'
NA
NA
Depth
1. EXCA VA TION S This section not applicable
a. Amount of material to be excavated! from below NHW or NWL in b. Type of material to be excavated.
cubic yards.
c. (i) Does the area to be excavated include coastal wetlands/marsh
(CW), submerged aquatic vegetation (SAV), shell bottom (SB),
or other wetlands (WQ? If any boxes are checked, provide the
number of square feet affected.
E]CW EISAV FISB
OWL E]None
(ii) Describe the purpose of the excavation in these areas:
d. High -ground excavation in cubic yards.
12. DISPOSAL OF EXCAVATED MATERIAL ®This section not applicable
a. Location of disposal area. b. Dimensions of disposal area.
c, (i) Do you claim title to disposal area?
E]Yes E]No F_1NA
(ii) If no, attach a letter granting permission from the owner.
e. (i) Does the disposal area include any coastal wetlandslmarsh
(CW), submerged aquatic vegetation (SAV), shell bottom (S13),
or other wetlands (WQ? If any boxes are checked,, provide the
number of square feet affected,
Elm [IsAv EISB
OWL E]None
(ii) Describe the purpose, of disposal in these areas:
d. (i) Will a disposal area be available for future maintenance?
E]Yes []No nNA
(ii) If yes, where?
f, (i) Does the disposal include any area in the water?
E]Yes E]No 171NA
(ii) If yes, how much water area is affected?
E M,-VED
=1
MAR 2 2 2023
DCM-EC
7,1524,108-2k'= .,,, 1- El W,3­4RC OAS T ;: revisod� 12/26/06

Forirri DCM IMPr ­2 FH1, r,";oq10 ',2' c)f 2),
3. SHORELINE STABILIZATION 0 This section not applicable
(If development is a wood groin, use MP-4 — Structures)
a. Type of shoreline stabilization:
E]Bulkhead MRiprap nBreakwater/Sill ElOther:
c. Average distance waterward of NHW or NWL: 6'
e, Type of stabilization material:
Rock rip -rap
g. Number of square feet of fill to be placed below water level
Bulkhead backfill Riprap 2,640 s
Breakwater/Sill Other
i. Source of fill material.
Inland Quarry
4. OTHER FILL ACTIVITIES
(Excluding Shoreline Stabilization)
a. (i) Will fill material be brought to the site? [DYes E]No E
If yes,
(h) Amount of material to be placed in the water ramp
3cu.yds. Rock, revetment 2,640 sf.
(iii) Dimensions of fill area Ramp - 15'x20'. Rock 6'x440'
(iv) Purpose of fill
Concrete base for boat ramp and rock revetment.
b. Length: 440'
Width: 6'
d. Maximum distance waterward of NHW or NWL: 6'
f. (i) Has there been shoreline erosion during preceding 12
months?
MYes []No nNA
(ii) If yes, state amount of erosion and source of erosion amount
information.
1'-2' according to owners observations.
h. Type of fill material,
Granite or marl
[:] This section not applicable
NA b. (i) Will fill material be placed in, coastal wetlands/marsh (CW),
submerged aquatic vegetation (SAV), shell bottom (SB), or
other wetlands (WL)? If any boxes are checked, provide the
number of square feet affected.
NCW 105-120 sf EISAV _ EISB
E]WL _ E]None
(ii) Describe the purpose of the fill in these areas:
Coastal wetlands will be imparted for new boat ramp.
5. GENERAL
a. How will excavated or fill material be kept on site and erosion b. What type of construction equipment will be used (e.g., dragline,
controlled? backhoe, or hydraulic dredge)?
NIA Backhoe, small tractor, dump truck.
c. (i) Will navigational aids be required as a result of the project?
E]Yes ENo EI'NA
(ii) If yes, explain what type and how they will be implemented.
d. (i) Will wetlands be crossed in transporting equipment to project
site? E]Yes ENo EINA
(ii) If yes, explain steps that will be taken to avoid or minimize
environmental impacts.
t U,
03/20/23 Authorized agent - Doug Dorman MAR 2 2 202
Date Applicant Name
Smith Property
Applicant Signature
Project Name
252-808.2808 :' 1 -888­4RC'0AS"F revised. IZ26/06

Form DCM MP-3
UPLAND DEVELOPMENT
(Construction and/or land disturbing activities)
Attach this form to Joint Application for CAMA Major Permit, Form DCM MP-1. Be sure to complete all other sections of the Joint
Application that relate to this proposed project. Please include all supplemental information.
GENERAL UPLAND DEVELOPMENT
a. Type and number of buildings, facilities, units or structures
proposed.
0
c. Density (give the number of residential units and the units per
acre).
a. If the proposed project will disturb more than one acre of land, the
Division of Land Resources must receive an erosion and
sedimentation control plan at least 30 days before land -disturbing
activity begins.
(i) If applicable, has a sedimentation and erosion control plan been
submitted to the Division of Land Resources?
[]Yes ®No E3NA
(ii) If yes, list the date submitted:
b. Number of lots or parcels,
1
d. Size of area to be graded, filled, or disturbed including roads,
ditches, etc.
Boat ramp access drive 400 sf
f. List the materials (such as marl, paver stone, asphalt, or concrete)
to be used: for impervious surfaces.
Gravel driveway.
g. Give the percentage of the tract within the coastal shoreline AEC to h. Projects that require a LAMA Major Development Permit may also
be covered by impervious and/or built -upon surfaces, such as require a Stormwater Certification.
pavement, building, rooftops, or to be used for vehicular driveways (i) Has a site development plan been submitted to the Division of
or parking. Water Quality for review?
6%. E]Yes NNo, nNA
i. Give the percentage of the entire tract to be covered by impervious
and/or built -upon surfaces, such as pavement, building, rooftops,
or to be used for vehicular driveways or parking.
11.5% of uplands
j. Describe proposed method of sewage disposal.
Existing conventional septic system.
(ii) If yes, list the date submitted:
k, Have the facilities described in Item (i) received state or local
approval?
E]Y,es ®No ONA
If yes, attach appropriate documentation.
1. Describe location and type of proposed discharges to waters of the m. Does the proposed project include an innovative stormwater
state (e.g,, surface runoff, sanitary wastewater, industrial/ design?
commercial effluent, "wash down" and residential discharges). [:]Yes F1No [DNA
Surface runoff If yes, attach appropriate documentation.
RECEIVED
manwiv,
252,r808,,28082 -,. '1-8884RCOAST -: DCM-EC reviseA� 12)26M6

Form DC1VJ hAR,3 (Upivand 2 of 2
m. Describe proposed drinking water supply source (e.g., well, n. (i) Will water be impounded? [JYes ENo EINA
community, public system, etc.) (fl) If yes, how many acres?
Dare County public water supply.
0. When was the lot(s) platted and recorded?
03/07/1988
03/20/23
Date
Smith Property
Project Name
Agent - Doug Dorman
Applicant Name
`Applicsignature
p. If proposed development is a subdivision, will additional utilities be
installed for this upland development?
E]Yes E]No ONA
RECEIVED
MMIRM
252-608-2('N't :. J revked: 121216Mi

ADDlicant: John & Sherry Smith
Selection
Development Type
Fee
DCM %
DWO %
(14300 1601 435100093 1625 6253)
(24300 1602 435100095 23411)
I. Private, non-commercial
E:]
development that does not
$250
100%($250)
0%($0)
involve the filling or
excavation of any wetlands
or open water areas:
II. Public or commercial
El
development that does not
$400
100% ($400)
0%($0)
involve the filling or
excavation of any wetlands
or open water areas:
El
Major Modification to a
$250
100%($250)
0%($0)
LAMA Major rmit
lit. For development that
involves the filling and/or
excavation of up to I acre
of wetlands and/or open
water areas, determine if A,
B, C, or D below applie&
III(A). Private, non-
commercial development, if
$250
100%($250)
0%($0)
General Water Quality
Certification No. 4175 (See
attached ) can be applied:
III(B). Public or commercial
development, if General
$400
100%($400)
0%($0)
Water Quality Certification
No. 4175 (See attached)
can be appliedA.
III(C), If General Water
Quality Certification No.
$400
60%($240)
40%($160)
4175 (see attached) could
be applied, but DCM staff
determined that additional
review and written DWQ
concurrence is needed
because of concerns
related to water quality or
aquatic life:
III(D). If General Water
Quality Certification No.
$400
60%($240)
40%($160)
4175 (see attached) cannot
be aDDlied:
IV. For development that
involves the filling and/or
$475
60%($285)
40%($190)
excavation of more than
one acre of wetlands and/or
open water areas:

NG Division of Coastal Management
Cashier's Official Receipt 27221 @13 C D
fate: —3j(c 2-- 20
)"1 -11
Received Fron,
Permit No.: 1h Q-"-k A
Check No.:
Applicant's Name:
County:
Project Address:
Please retain receipt for your records as proof of payment for permit issued.
Signature of Agent or Applicant,
Signature of Field Representative: —'i Date:

ATLANTIC ENVIRONME
PO Box 3266, Kitty Hawk, NC 2
. ..... . ... .
• Complete items 1, 2, and 3.
• Print your name and address on the reverse
so that we can return the card to you.
• Attach this card to the back of the mallple�
or on the front if space permits.
1. Article Addressed to:
A. lgqn dtur6,,,,Ip4
X
B. Received by
LE-1
lcry
D., Is delivery address different from item i ? LJ Yes
If YES, enter delivery addMMPty 202Y No
March 20, 2023 3. Service Type
CI Adult Signature
0 Adult Signature Restricted Delivery
flWCartified Mail@
95
0 Certified Mail Restricted Delivery ,90 9402 7859 22'34 0517 30 El Collect on Delivery
2. Article Number ffiransfer from servicA lah ollect on Delivery Restricted DeTivery
Insured Mail
Charles Pereira 7022 13410 0000 5530 6397 Insured Mail Restric
I (over$500)
1008 Megson Couil PS Form 3811, July 2020 PSN 7530-02-000-9053
Raleigh, NC 27614
Dear Mr. Pereira,
This notification letter is in reference to John and Sherry Smiths property located at 47047
Rocky Rollinson Road in Buxton, Dare County, North Carolina. The Smiths are proposing to
install a boat ramp to access the existing basin and adjacent waters of the Pamlico Sound. In
addition the Smiths plan to install 440 feet of rock rip -rap along their property shoreline to
protect the existing wetlands from further erosion.
• Priority Mail ExpressO
as Registered MaIlTm
• Re Istered Mail Restricted
Delivery
• Signature ConfirmallonTM
0 Signature Confirmation
Restricted Delivery
As the adjacent riparian property owner to the aforementioned project, I am required to notify
you of the development in order to give you the opportunity to comment on the project. The
attached drawings, applications, and project narrative show in detail the proposed improvements.
Please review the attached drawing and should you have any objections or comments concerning
this project, please send your written comments to Ron Renaldi, District Manager, Elizabeth City
Regional Office, 401 South Griffin Street, Suite 300, Elizabeth City, NC 27909, or call 252-264-
3901 within 30 days of your receipt of this notice, Such Comments will be considered by the
Department in reaching a final decision on the application. No comments within 30 days of your
receipt of this notice will be considered as no objection. If you have any questions on this
project please call me at 252-599-2603, or e-mail me at
.tltatdcl. . ...
Sincerely,
Doug; boim-a'n
Allan le bivironniental Cotisullants, LLC
RECEIVED
MAR 2 2 2023
DCM-EC
Cell: [phone] Off ice- [phone] Email: dougdaec@gmal,l.com
. . . . . ...............

A rI.ANTIC ENVIRONMENIAL CONSUI TARTS, LLC 5 T' �i ,r- i c tl.'f
PO Box 3266, Kitty Flawk, NC 27949
CERTIFIED MAIL
RETURN RECEIPT RE QUESTED
February 22, 2023
Charles Pereira
1008 Megson Court
Raleigh, NC 27614
Dear Mr. Pereira,
This notification letter is in reference to John and Sherry Smiths property located at 47047
Rocky Rollinson Road in Buxton, Dare County, North Carolina. The Smiths are proposing to
install a boat ramp to access the existing basin and adjacent waters of the Pamlico Sound.
As the adjacent riparian property owner to the aforementioned project, I am required to notify
you of the development in order to give you the opportunity to coauncnt on the project. The
attached drawings, applications, and project narrative show in detail the proposed improvements.
Please review the attached drawing and should you have any objections or comments concerning
this project, please send your written comments to Ron Renaldi, District Manager, Elizabeth City
Regional Office, 401 South Griffin Street, Suite 300, Elizabeth City, NC 27909, or call 252-264-
3901 within 30 days of your receipt of this notice. Such Comments will be considered by the
Department in reaching a final decision on the application. No comments within 30 (lays of your
receipt of this notice will be considered as no objection. If you have any questions on this
project please call me: at 252--599-2603, or e-mail me at d0L 1, Lkj( )11
!HX0111-
Sincerely,
M
'�'bo'�ug Db! man �n
At anlic Environmental Consullaws, LLC C3
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El Return Receipt (electronic)
[]0arlified Mall Restricted Delivery $
E] Adult Signature Required $
C_]Adult Signature Restricted Delivery $
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Cell: (252) 5�)9­2603 Office: [phone] 0
I I I I - - 1-1 1 1 1 _ _ I.' _5 ­'.!'��20.c�.l ...........

AUTHORIZATION TO ACT AS REPRESENTATIVE FORM
Property Legal Description:
DEED BOOK: 1901 PAGE NO: 58
PIN NO.: 053719700892
PROPERTY STREET ADRESS: 47047 Rocky Rollinson Read, Buxton NC 27920
Please Print:
Property Owner: John Smith
Property Owner: Sherry Smith
The undersigned property owners of the above noted property, so hereby authorize
Doug Dorman of Atlantic Environmental Consultants, LLC to,
(Contractor/Agent) (Name of consulting firm)
1. Act on my behalf and take all actions necessary for the processing, issuance and
acceptance of permits and/or certifications and any all standard and special
conditions attached.
2. Enter the property to obtain site information including inspections with regulatory
agencies (Dare County, North Carolina Department of Environ mental Quality,
U.S. Army Corps of Engineers, etc.) for the purpose of obtaining permits and/or
certifications.
Property Owners Address (if different than property above):
33576 S Main Street, Townvine. PA 16360
Property Owners Telephone Number: 814-694-5554
We hereby certify that the above information submitted in this application is true and
accurate to the best of our knowledge.
0:nemoAnz�51 -----
)x(thorized Signature and Title
0
Authorized Signature and Title
Date: 02-21-23 Date: 02-21-23

0
EXEMPT
DARE COUNTY TAX
CO,LL CTOR
Doc Id: 6312547
0: 1901 P: 58 Receipt #: 12-0026
0612112012 1064 AM NCOXcise Tax pd $0 00
Doc Code: CID NC
vAnzolla MoMU ,;mit),. Register of Deeds Dare C07
6312547 B: 1901 P: 58 Page I of 5 6/21/12 10754 AM
mill K WhIll.k1lb"101AW 191 lot pit 161 th NI III
Preparc-6 Christopher L. Seawell
Return too Dixon & Dixon
0 P. 0. Box 750
( Avon, NC 2791.5
Tax Collector C n,,Thai No Delinquent Taxes
NORTH CAROLOA Are Due. Date =y--�� Certification
DARE COUNTY expires Jan. 61h of the year following Ification date.
T141S DEED OF I CT1,0N made and entered into this the 7th day of May, 2012, by
and SHAWN M. EGAN L U EnN K. EGAN, ("Grantor"); and J014N 0. SMITH and
wife, SHERRY L. SM111 antee 336 S. Main Street, '1'ownv i Ile, PA 16360.
WITNESSETH:
WHEREAS, said Grantor);— tofore executed to Grantee a certain deed recorded in Book
1888, Page IS, in the Office of the �*ister of Deeds of Dare County; and whereas, by mutual
mistake said deed contained an error the description in that one page of the description was
mistakenly omitted; and
WHEREAS, said parties are desirou6correcting,said mistake.
0
Now, therefore, said Grantor, for the p®r ose of correcting said error and in consideration
of the suin of One Dollar, to them in hand paid, is bargained and sold and by these presents does
grant, bargain, sell, and Convey unto said Gmntee,*-ir heirs, successors and assigns a certain tract
or parcel of larid lying and being in Hatteras Townai Dare County, North Carolina, and more
particularly described in Exhibit "A" attached.
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and
appi4rtenances thereto belonging to the Grantee in fee simple,
(SIGNATURE:,S, ON FOLLOW[NG GES)
li,
0
6
0

fN WITNESS WHEREOF, the Grantor and Grantee have duly executed the foregoing as of the
day and year first above written,
�AL)
Shawn M. Egan
SOF C ri� Tyj(1� 7&
10- Notary Public of the aforesaid County and State, do certify that Shawn M, Egan
personall. peared came before me this date and acknowledged the execution of the foregoing
instrument.
750 06— &0 1-
Witne y hand and official seal or stamp, this tl e day of-Mftr
c 0' 2012
CCC biota �Public��-
My Coln fission e4res:
I t --w BARBARA 14. TANDY
Notary Pubfic. State Of NowYork
No. WTA6086001
ouslified in Suffolk County
S'
COMMISSIon Expires 01/13120 L—
0
6
0
0
V1,
0
6312547 8: 1901 P: 58 Pago 2 o 5,6/21/12 10:54 AM
wIII wil 1112, NAAh"AA1.4141 Nit HP11.10. h 1111!11
6
0

XAN
EXl IBTT A.
Located inn the Village of Buxton, Hatteras To- wriship, mare County, North Carolina, consisting
of 8.57 acreore fully described as follows:
0
Beginning at aoxisting iron pipe, said existing iron pipe being located on the Southeast corner
of the lands no'
formerly owned by Drank Mounts, said existing iron. pipe being located
South 80 deg.. 3n. 15 sec. East 166.66 feet from the center point of the terminus of the 60
foot right of way of rth Carolina Secondary Road 1230, also known as Rocky Rollinson road;
from said beginning ' it along the Eastern property line of that lot or parcel of land now or
formerly owned by FrarK Mounts North 07 deg. 45 min.. 00 sec. bast 244.96 fret to an iron pipe;
thence continuing along the Eastern property line of that lot or parcel of land now or formerly
owned by frank Mounts North 07 deg. 45 min. 00 sec. East 24 feet, more or less, to the mean
high water mark of the Para +o Sound; thence turning and running along the mean high water
mark of the Pamlico Sound YOa generally Southeasterly direction to a point, said point being
where the Western property li1S.f that lot or parcel of land now or formerly owned by Issac
Jennette intersects with the meaKIth"t-western
"h water stark of the Pamlico Sound, said point being on an
approximate bearing of Southeg. 27 min. 13 sec..East and a distance of approximately
200.69 feet; thence turning along property line of that lot or parcel of land now or
formerly owned by Issac Jennette SoulID3I deg. 00 min. 00 sec. East 21 feet, more or less, to an
iron pipe; thence continuing along the stern property line of that lot or parcel of land now or
formerly owned by Issac Jennette South deg. 00 min. 00 see. East 879.38 feet to an iron pin;
thence continuing along the Eastern property line of that lot or parcel of land now or formerly
owned by Issac Jennette South 31 deg. 00 U. 00 sec. East 43.85 feet to a paint, said point
being located in the approximate center line o uddy Marsh Ditch; thence turning and running
along the approximate center line of Muddy h Ditch North 86 deg. 00 min. 00 sec, West
499.00 feet to a point; thence turning and runnin%Ianow
the center line of Muddy Marsh bitch a
bearing of North 80 deg. 00 min. 00 sec. best 28eet to a point, said point being located oil
the Eastern property line of that lot or parcel of or formerly owned by Malvern H,
Wyche Jr.; thence turning and running along the Ettsrn property line of that lot or parcel of
land now or formerly owned by Malvern H. Wyche, Jr. North 07 deg. 45 ruin. 00 sec. East 23.24
feet to an existing iron pipe; thence continuing North 07 deg. 45 min, 00 sec. East 490.19 feet to7
the point and place of beginning.
"There is further hereby conveyed an easement for ingress, eg�s and regress 10 feet in width,
said easement being more particularly described as follows:,,
Beginning at an existing iron pipe, said existing iron pipe being to 'd on the Southeast corner
of the lands now or formerly owned by Frank Mounts, said existir iron tripe being located
6312547 B: 1901 P: 58 Paige 4 of 5� 1/12 19:54 AM
P "N 1N � I "IOV INIANCIOUH h 11111
6
0

IN WI11'-ESS WHEREOF, the Grantor and Grantee have duly executed the foregoing as of
the day and year first above written.
` j 7
0 {SEAL)
TE OF �
f�IN`CY/C Y 0F'
1, a Notary Public of the aforesaid County and State, do certify that Lauren K. Egan
persona appeared carne before me this elate and acluiowledged the execution of the foregoing
instrtrnr
W' s my hand and official seal or sfarnp, t the day o M° 012.
1Vot ublic
My Co10 aces: CYNTHIA J. KESSLE=R
hlotary Pub ic, State of New York
No. Ot K S006684
oualified in Suffolk 'County
commission Expires January 4,
x2QZ Is
16
0
pw
6312547 p : 1901 �' . 5�8 Page 3 of 5� R 21 / 12� 10 : 54 AM
Ill P171 1 �,1411,144 . M 11A � irM� 0111111
0

North 80 deg. 36 min. 15 see. East 166.66 feet from the center point of the terminus of the 60
foot right of way of Norith Carolina Secondary Road 1230, also known as Rocky Rollinson Road;
(from said beginning point North 80 deg. 36 mill. 15 sec, West 166.66 feet to a point, said point
1 g the center point of the terminus of the 60 foot right of way of North Carolina Secondary
RWaD 1230; thence turning and running along the terminus of the 60 foot right of way of North
Car)el* a Secondary Road 1230 South 10 deg. 58 min. 00 see, West 10.0 feet to a point; thence
tumi d running South 80 deer. 36 min. 15 sec. East 166.66 feet, more or less, to the
Wester1 10st property line of the lands above described; thence turning and running North 07
deg. 4 1P. 00 sec, East 10.0 feet, more or less, to the point and place of begirming,
Reference i-16reby made to that map or plat entitled in part "Revised Map of Survey for the
Heirs of Willioa T. Barnett, Buxton, Hatteras Township, Date County, North Carolina" by Ray
Meekins Land I eying which is recorded in Plat Cabinet C, Slide 178D, reference to which is
hereby rnade for ore complete and precise description of the lands being herein conveyed.
for
6
0
A
6312547 B: 1901 P: 58 Page 5 of 5 6/21/12 1 1-M
mill NO, pal IFW�IIROA lei i H W M1,10 1 04 V I
6
0
f,

2-6

Ginail - 40 1 /BulTer Pre -filing Meeting Request- Smith LAMA Major...
littl)s:Hiiiail.googic.coiii/i-nait/ii/O/?ik-6f'76ba I c92&view=pt&search=...
Doug Dorman <[e-mail]>
401/Buffer Pre -filing Meeting Request- Smith CAMA Major Application
1 .-
Doug Dorman <[e-mail]>
To: 401 [e-mail]
Project Name: Smith Boat Ramp
County: Dare
Applicant Name: John & Sherry Smith
Applicant Email: dO([e-mail]
Doug Dorman
Atlantic Environmental Consultants, LLC
PO Box 3266
Kitty Hawk, NC 27949
252-261-7707 office
252-599-2603 cell
21 February 2023 at 15:32
MAR 2023
L) 4` IN
."*
1 of 1 3/19/2023,9:11 AM

Carver, Yvonne
From: Doug Dorman <[e-mail]>
Sent: Thursday, April 13, 2023 5:13 PM
To: Carver, Yvonne
Subject: [External] Fwd: 401/Buffer Pre -filing Meeting Request- Smith LAMA Major Application
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Yvonne,
This is what I get from DWR. Are others getting something different?
a«
Project Name: Smith Boat Ramp
County: Dare
Applicant Name: John & Sherry Smith
Applicant Email: [e-mail]
This email is to fulfill the pre -filing meeting request requirement put in place on Thursday April 7, 2022 when the
Environmental Protection Agency's "Clean Water Act Section 401 Certification Rule' ('Federal Rule") was reinstated to its
previous version which originally became effective on September 11, 2022. In accordance with 40 C.F.R. Section 121.4(a)
'At least 30 days prior to submitting a certification request, the project proponent shall request a pre -filing meeting with
the certifying agency'. In accordance with 40 C.F. R section 121.5(b)(7), and (c)() all certification requests shall include
documentation that a pre -filing meeting request was submitted to the certifying authority at least 30 days prior to
submitting the certification request.
Doug Dorman
Atlantic Environmental Consultants, LLC
PO Box 3266
Kitty Hawk, NC 27949
252-261-7707 office
252-599-2603 cell

Carver, Yvonne
From: Doug Dorman <dougdaec@gmai|zonn>
Sent: Thursday, April 13,2023 5:34 PM
To: Carver, Yvonne
Subject, Fwd: [External] Fwd:
CAUTION: External email. Do not click links or open attachments unless you verify.Send all suspicious email asamattachment to
Report Spam.
Yvonne,
This is the response I received from DWR regarding the 401 prefiling.
---------- Forwarded message ---
Fnonn:Strickland, Bev
Date: Mon, 21Jul 2O22at1O:33
Subject: RE: [External] Fwd:
There is no feedback any more. The below email is all you need.
Beverly Strickland (she/her)
Laserfiche Administrator
Division of Water Resources
Department of Environmental Quality
919- O73876 Office
BE
From: Doug Dorman
Sent: Monday, July 11,2D221O:27AM
To: Strickland, Bev ;Monta|vc\Sheri A

CAUTION: External email. Dunot click links oropen attachments unless you verify. Send all suspicious email asam attachment to
Beverly 0Sheri,
| submitted a oref|ing request for the project below onJune 6, 2022 and | have not received a 30 day review beck
yet. Can you please let me know what the status is?
Thank you,
Doug Dorman
Atlantic Environmental Consultants, LLC
Kitty Hawk, NC 27949
252-261-7707 office
252-5,99-2683meU
---------- Forwarded message ---------
From: Doug Dorman
Date: Mon, 6Jun 2O22 atOQ:30
Subject:
To: <401PreFile2ncdenr.gov>
This a PreFile request for a CAMA major permit application located at 142 Williams Drive, Knots Island, Currituck County.
Please fil�l out the following information:
Project Name: Phillip Jethro
Cnuoty:CurMtumh
Applicant Name: Atlantic Environmental Consultants, LLC
Applicant Email:

This email istofulfill the pre -filing meeting request requirement put implace mnThursday April 7,2022when the
Environmental Protection Agency's 'Clean Water Act Section 401Certificahon Rule' /^Fedena| Rule') was reinstated to its
previous version which originally became effective on September 11, 2022. In accordance with 40 C.F,R. Section 121.4(a)
'At least 30 days prior to submitting a certification request, the project proponent shall request a pre -filing meeting with
the certifying agency'. In accordance with 40 C.F. R section 121.5(b)(7), and (c)(5) all certification requests shall include
documentation that pre -filing meeting request was submitted tothe certifying authority at least 30 days prior to
submitting the certification request.
Doug Dorman
Atlantic Environmental Consultants, LLC
Kitty Hawk, NC 27949
252-2161-7707 office
252-599-2603ceU

0 CAMA $1 DREDGE & FILL
1-6,
(A) B C. D
GENERAL PERMIT Previous permit #
k 1N'-ew DModification DComplete Reissue ❑Partial Reissue Date previous permit issued ----77,77-77.
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 I SA NCAC t 00. 006
D9 Rules attached.
Applicant Name Project Location: County_
Address
Street Address/ State Road/ Lot #(s)
City State (y, C
Phone # (Liflt A-10 E-Mail" . . .... ...
Authorized Agent A, . AIAA i I A? 0 0 " ('(. ��c City ZIP 2
M, Cw
Affected
REW 56 PTA DES
n— PTS
Phone#
River Basin
S r/ 11 13 4t,
AEC(s) El OEA
El HHF El IH D UBA 0 NIA
Adj. Wtr. Body
Uf I 41f' (
(nat rQnN/unkn
E) PYI&-
ORW: yes I
60-)
PNA
yes
Closest Maj. Wtr Body_ r1l 0 t Yet
Type of Project/
Activity .
(lo j%,5 kLl,
IT50, 11-11��)rc.-'o
e! od
16C r.
(
'i)(J
(Scale: S
Pier (dock) length
x
t
Fixed Platforms )
I --.. I
PTP-T-I-
�-�
Floating Platform(s)
Finger pler(s)
Groin length
number
Bulkheadejipr. length:�-- �,'
avg dFs6nce offshore
max distance offshor-=
Basin, channel
cubic yards
Boat ramp
.Boathouse/ Boatlift—
Beach Bulldozing_
Other
Shoreline Length
SAV: not sure yes (I
Moratorium: Q'--/a) yes no
Photos: i y no
Waiver Attached::yes rnol
A building permit may be required by: I-V r(El See note on back regarding River Basin rules.
Note Local Planning jurisdiction)
Notes/ Special Conditions J.
L , r ir' ol V
Ag 'I r'plIcaAt Printed Name
Please
Signa re Please read compliance statement on back of permi
Application, Fee(s) Check #
Permit OWWsPrinted Name
Signature
2,"1 1 leq
issuing Date Expiration Date

B C DOurq NY 89632
1) %,,CAMA EJ DREDGE FILL Previous permit -
GENERAL PERMIT Date previous permit Issued
few E]Modification F] Complete Reissue []Partial Reissue
As authorizedby the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
ISANCAC L] Rules attached. r27 General Permit Rules avail" at the following, link: yny .X'govl
Applicant Name AthorizedAntGr
Addre s3 ��.�.,_.
b
-
s __M'Aa� Project Location (County):
city 'J-6 WA Jk State ZIP Street AddrosfStte R."L.t #(s) <
Email ka S'n 1, V-Z,4%, Subdivision
city B't -'e. k1 zip '7-..;7 TV:.,
Affected FICW MEW FPTA ES L] PTS Adj. Wtr. Body B it e-, 4-b .a oQ_Cr--LK (natImantunk)
AEC(s): EJOEA 0114A UUW E] SPIMA PW5 Closest Mal. Wtr. Body
ORW;yes/ CO, PNA: ye!14!�)
Type of Project/ Activity
Shoreline Length Z!�f
Access length
Pier (dock) length K
? Fi d Platform(s)
Floating Platform(s)
Finger pler(s)
Tota Wwlf'o
Groin le-gtnr��
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/sill
Max d istance/ length
Basin, channel
Cubic yards
Boat ramp
Boathouse 62antit—J—ZI X, /�
Beach Bulldozing
Other
&,a
SAV observed: yes no �
Moratorlurn,: a yes 5Z7�
Site Photos: CD s
Riparian Waiver Attached: yes 0_513!�
A building permitlzoning permit may be required by:
Permit Conditions
A. -
or .0 / C'
C-<�A A -4- +- A *.,-. S --- 5 -f
"T� Air P/ rzr
FQ_r_ . 0 V, I- r- I <�_ 9* — s _4�- I La I 6,ew, a vm-- q c-q­a.-
VVV 4-k -t 4- L co et - /ff- I/ 'Z rft. *'-4- 6_4 '% ior A-
J
4 C.'> 4- faw.,
— (Scale: A/r� )
-f 153, tj
TAI'VIRAtINEUSEISUFFER (circle one)
See note on back regarding River Basin rules
See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial) f"
e'
Agent orIppliJ6nt P . TED Name Permit Officer's PRINTED Name
Signature **Pleaie read compliance statement on back of permit!"
Application Fee(s) Check #/Money Order Issuing Date Expiration Date

.� ,j

w
AP.
A,
Al