86101A_Town of Souther Shores_20211005

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0t°°t d-AMA ) DREDGE & FILL N9 86 101 d B C D
ERAL PERMIT Previous permit
V E� V Date
ate previous permit issued ____
ANew []Modification ❑ Complete Reissue (-] Partial Reissue
As authorized by they State of North Carolina. Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to;
I SA NCAC �` Qd Rules attached. j General Permit Rules avait66 at the following link: vrnw deo nc Qas�CJitMAniles
Applicant Name a J Q Authorized Agent
Address 559:6 N • via S /ai!r-.. r(. -L ,+�. Project location (County):
City M;)rl �j5tate , ZIP . � T ���___ Street Addresz/State Raadilot #(s} �,,j' l� _1�� Y_�.5
Phone#(ftL .6L - 2�.�awid By ► 61w I -Q + L -_$ sSltJzz�
Email a W I( C�it1 >11►1Q.✓Y► jQ ," Q_� Subdivision _ Q.{/Y1 �ir1D1/C:`J L41/tJ'.
City om -W-4&n 6titaV'--zip2"},q-i
/1 ��
Affected �CW<EW PTA �ESPTSAdj. Wtr. By od,_�yQyt�_l4,j�j._�ti..,. nat/m unki
AEC(s): �OEA rr�IHA c uW rL_7 SPIMA E! PWS Cat M4. Wtr. Body Y1
ORW: ye tri PNA(Dno
Type of Project/ Activity `r
(Scale: N-rS)
ShRraiiRv t/K�Ptlf � L C�'
Access Length
Pier (dock) length
Fi:ied Platfo". s}
Floating Platform(s)
Finger pier(s) TT
Total Platform area
Groin length/M
ulkhea Riprap length I�
Avg distance offshore _ 'F
Breakwater/Sill
Max distance/ length 1 1
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatph
Beach Bulldozing
Other
.A.
CA,N All
1
SAV observed:�,� yes (:/ / T v �e� 6-1W-
Moratorium ,�:� yes no �/'
Site Photos: no
Riparian Waiver Attached: es QQno ` innn
A building permit/coning permitm y�e required by _ yy_Y1 QC i�[]lalf-i�i✓Ji*1 _y� Q_�'�
Permit Conditions Olt JOn.I(Y
Q
l
JOn
FITARIPAMINEUSE/BUFFER (circle onej
See note on back regarding River Basin rules
See additional notes/conditions on back
1 AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please initial}
ent rApplicant PRINTED Name Permit cer's PRINTED Tarr}e
Signature "•Please read compliance statement on track of per Signature
Application Fee(,! Check d/Money Order Issuin Expiration Date

Lyn Small Inc, Marine Construction
AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Town of Southern Shores c/o David
Bradley — —
Mailing Address: 5375 N Virginia Dare Trail, Southern Shores
Phone Number: _252-256-2503
Email Address: [e-mail],_
I certify that I have authorized Lyn Small Inc_
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
nE!ce:>sary for the following proposed development: Bulkhead
at my property located at Sassafras lane, Southern Shores
in _—Dare—County.
l fWthermore certify that / am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permil application.
Prcperty Owner Information:
Signature
Pnnt or e Name
_[�I.NCV�Ll
Title
This, cErtification is valid through 7 li1 / 2021
Date
This certification is valid through _12 / 31_/-2021

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: Town of Southern Shores c/o David Bradl
Address of Property:
Sassafras Lane, S Shores
Mailing Address of Owner: 5375 N Virginia Dare Trail, S Shores
Owner's email: dbradley@southernshores-pq,6�9\4 Phone#: [phone]
Agent's Name: Lyn Small Inc.
Agent's Email: [e-mail]
Agent Phone#: [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 for this
permit has described to me, as shown on the attached drawing, the development they are proposing. A
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' tba ,-
Si�lnature of Adjacent
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Owner
Typed/Printed name of ARPO:
J eL
Mailing Address of ARPO:
1 74)
(.+-
r S� u�"�. �r �, s��r�g i\,1C- 2_71�7
ARPO's email:�� �Skoyk^4ARPO's Phone#: 7423 -2Y� 'L 711�3_7
Date: *waiver is valid for up to one year from ARPO's Signature*
Revised May 2021

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: Town of Southern Shores c/o David Brad
Address of Property:
Sassafras Lane, S Shores
Mailing Address of Owner: 5375 N Virginia Dare Trail, S Shores
Owner's email: dbrad ley@so uthernshores-%@} Phone#: [phone]
Agent's Name Lyn Small Inc.
Agent's Email: [e-mail]
Agent Phone#: [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 for this
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.
1 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 15from my area of riparian access unless waived by me
(this does not apply to bulkheads or riprap revetmeros). (If you wish to waive the setback, you must sign
the appropriate blank below.) r ��
I DO wish to waive some/all of the 15setback
-O R-
I do not wish to waive the 15' setback requirement (initial the blank) tf e
Signature of Adjacent Riparian Pr?Rerty Owner:_,A &I crt)
Typed/Printed name of ARPO:
Mailing Address of ARPO:
ARPO's email: } & 1 � �Z_ ` C 1!' gk1s Ph e#: A� `
Date: 5 F� Zi *waiver is valid for up to one year from ARPO's Signature`'
Revised May 2021

T
0
c a
ati'
170 Sassafras Lane
Billingsley, Joel & Ann
Existing Vin
g Wood Bulkhead
177 Sassafras Lane
Angileri, Richard & Camille

This map is prepared
from data used for the
inventory of the real
property for tax
purposes. Primary
information sources such
L
as recorded deeds, plats,
wills, and other primary
r _�
public records should be
.0N
consulted for verification
of the information
contained in this map.
".gat5
0 Sassafras
Southern or C, 27949
Parc 6000
600 :986817105
9 ners: Billingsley, Joel T -Prim Tax DistrictK1974
or
Owner Subdl ' n: So/111 120
Billings Ann K -Prim Owner
Building lue• 35,500 Lot BLK-Sec:21 Sec:
Land Val : 95,400 Prope tial
Mis alue: $30, 0 B 'dinh
al Value: $561,20 Year

I