79422A_Baker, Jeffrey_20210909

QCAMA / ❑ DREDGE & FILL
GENERAL PERMIT
R(New ❑Modification ❑Complete Reissue El Partial Reissue
N9 79422 A
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
{�n O Rules attached.
Applicant Name Se fit' e CLI 9�K�� Project Location: County 5
Address kz� _ j V Ci < n I C)
City t d p_ 0-0n States K ZIP o7 79 3 Z-
Phone # Gam` Z) 31 Z " 3 0 EE-Mail
Authorized Agent Y Ph K/ ll I t -C1
Affected ❑ CW ❑ EW JK PTA ❑ ES ❑ PTS
AEC(s):
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ WA
❑ PWS:
ORW: yes / no PNA yes / no)
t1(L Z
B C D
Street Address/ State Road/ Lot #(s) f p J # 3 3
Subdivision SY\u ca. Q
City 6e+fun zip
Phone # ( — )
River Basin �, }-a A k
Adj. Wtr. Body n f, c + (nat /man /unkn)
Closest Maj. Wtr. Body_ P
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Agent or Applicant Printed Name
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Signature Please read compliance statement on back of permit
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Application Fee(s) Check #
( i I > f,1,h I c.
Permit Officer's Printed Name
Signature '
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1 / 2 1
Issuing Date xpi tion 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 I) 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 how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves: Carteret, Craven, Onslow - (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet- and Pamlico Tyrrell and Washington Counties)
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)
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

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit.f *n
Mailing address:SZ:j
Telephone Number: �" `� v �j l•-1 - Cj�
I certify that I have authorized (agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of
?'n'-�- "—nLy ):L p
at my property located at
v
This certification is valid throughZa 3)- DD�;?l - (date).
(Property Owner Information)
ignature
"
Title, co. owner or trustee for prope y
Date
v
Telephone Number
Email Address

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: vel eu A
Address of Property: 11 3 7-L ge, , )VC, ,P 17, j yy
Mailing Address of Owner: (pSY )2Ee-W/orf Ap— ,27Q 1
Owner's email: Owner's Phone#: Q5d - i a — 53 1 a
Agent's Name:
Agent's Email:
Agent Phone#:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
I hereby certify that I own property adjacent to the above referenced property. The individual applying forthis
permit has described to me, as shown on the attached drawing, the development they are proposing. A
description or drawing, with dimensions, must be provided with this letter.
I DO NOT have objections to this proposal. I DO have objections to this proposal.
ff you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Gruen St., Ste. 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at [phone]. No response is considered the same as no objection if you have been
notified by Certified Mail.
WAIVER SECTION
I understand that any proposed 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
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
Ken
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner: lbw 42 EZL,1.d'
Typed/Printed name of ARPO: , � I /f0 r I t C0 A L1✓,b
Mailing Address of ARPO: 1 l TO W 'TA I LA, r✓ lEo >(n A/C � 7 V LJ
ARPO's email: ARPO's Phone#: 1�sc� cq,� S131
Date:-7/3 1 a I *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner:
Address of Property:
Mailing Address of Owner: 65hl 1A 129 1 r11A zd�-n 793
Owner's email:
Agent's Name:
Agent's Email:
Owner's Phone#: _ 94TA 3 141- f 5910
Agent Phone#:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacent Property Owner)
I hereby certify that I own property adjacent to the above referenced property. The individual applying forthis
permit has described to me, as shown on the attached drawing, the development they are proposing. A
­io, Ai—.n-zir%n z mimt ha nrnvided with this letter.
I DO NOT have objections to this proposal. I DO have objections to this proposal.
if you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at [phone]. No response is considered the same as no objection if you have been
notified by Certified Mail.
WAIVER SECTION
I understand that any proposed 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
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name ofARPO: _1�)4Y)d
Mailing Address of ARPO: // S- TrL +—
ARPO's email: ARPO's Phone#:
Date: 7 3 i• z-! *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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For tax purposes only. Not a legal oocument or survey. Perquimans nor State of NC assume any liability resulting from use of this map.

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