Sarageno, Susan

2
1-1CAMA / ❑ DREDGE & FILL No 71679 A B ; C°> D
GENERAL PERMIT Previous permit#
[PNew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality —7 /
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
f�$Rules attached.
Applicant Name t 7 rl
Address
City l State ZIP��
Phone # (T) i' E-Mail
Authorized Agent
Affected-- ElCW -DEW _dPTA .DES pPTS
AEC(s): OEA ❑ HHF ❑ 11H ❑ UBA ❑ WA
❑ PWS_:
ORW: yes Pno PNA yes / no!
Project Location: County 1 tt ;Y; l;
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIPS_
Phone # ( ) River Basin
Adj. Wtr. Body (' ili t '' r' f Ynat /man /unkn)
Closest Maj. Wtr. Body
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length
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avg distance offshore
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rn� distance offshore
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Agent or Applicant Printed Name
Signature Please readc p ce statement on back of permit
Application Fee(s) Check#

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 Resources. Contact the Division of Water Resources 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
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888ARCOAST
Fax: [phone]
(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:[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 - South of New River Inlet -
and Pender Counties)
http-.//portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

f AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
NAME OF PROPERTY OWNER APPLYING FOR PERMIT Susan Sarageno
ITUN l 1210M. IIp7.7DIY.
TELEPHONE NUMBER
19 Parsons Rd
Grantsboro, NC 28529
252-249-7206
I certify that I have authorized Dan Foley (agent/contractor) ,
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of Dock
at my property located at -Same-
This certification is valid through (1) Year (date).
Information)
Signature
Print or Type Name
Title, co. owner or trustee for property
Date
Telephone Number
Email Address

11-01-41- "lip i
Pf

8/14/2018
Property owners statement 02.jpg
(Name of -Property uwnerl
property located at l 4
on 13ro j- title -
ss, Lot, Block, Road, etc.)
in JGcw PIOA••Zco N.C.
(Cityffown and/or County)
has described to me, as shown below, the development proposed at the above
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND►OR DRAWING OF PROPOSED DEVhLVrmcry i
proposing development must fill in description below or attach a site drawing)
Ir
titre✓• �--- r L✓�+
WAIVER SECTION
lerstand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
t be set back a minimum distance of 16 from my area of riparian access unless waived by
(if you wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
YI do not wish to waive the 15' setback requirement.
lerty owner information)
iture
izs'fifo S?42ACot
,rType Name
�A,`SoN Q
g Addss�
iq'
14aft0p n1Lq,7at) L
-valid for one calendar year after signature'
Property Ov(nef mTormaavn)
� U
�me t
7!(0
1r/eryrail address
l
(Revised Aug. 2014)
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8/14/2018 Property ownes statement 01.jpg
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to v 5 A.v fdw
(Name o Property Owner)
r erty located at
s�
p op (Address, Lot, lock, Road, etc.)
on 13K04.t. tee(< , in r&C a L"-6r..1.eo N.C.
(Waterbody) (CitylTown and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposalx
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must 1711 in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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.
'XI do not wish to waive the 15' setback requirement.
Owner Information)
Sign re
.SUSAly SAsLAG A)a
Print or TypeA+2SName
�
Mailing Address
�'• fZ•fL1�'liS�3o (tct NC ��
City/Stat'ipP `
Telephone Ngmber/email address
Date
'Valid for one calendar year after signature*
n,,,4AdjaFent Plop
information)
°Tl or type rvame
PA izS� N` 1 '�-b
Nailing Address C
a"Vi{-$tSgt=U
City/statt'l4
Telephon eJJumper/email address
0' /_3 1�_
Date`
(Revised Aug. 2014)
https://mail.google.com/mail/u/0/?tab=wm#inboxll653488f50e76bde?projector=l&messagePartld=0.l 1/1

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