86200A_McKendree, William & Mary_20211015

'o`wrkkN [/CAMA ElDREDGE & FILL n
11'GENERAL PERMIT
Iv v Z$()Luu
Previous permit
Date previous permit issued
vB C Dv
[New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue
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:
I SA NCAC Rules attached. Q General Permit Rules available at the following link: www.dgq.nc.gov/CAMArules
Applicant Name �: 11 lower d'
Address x I I i-
City State _/v G zip ' 16
Phone # ( ?�) q 78 - 2 al I
Email a-, I l b(e k,"t L°i-� ( • GPI
Authorized Agent 0, C ! 'W ne!
Project Location (County): 6&ff:4t[ `k—
Street Address/State Road/Lot #(s) 1970 QrnAa 1 At.. L3
Subdivision
City
2L;1 ! C
4ffected ❑ CW EW PTA ❑ ES
PTS Adj. Wtr. Body c C�
Cam` f^� na an/unk)
4EC(s): ❑ OEA IHA ❑ UW ❑ SPIMA
PWS Closest Maj. Wtr. Body
/ins
r�
�l r . 47-e k,
DRW: yes no PNA: yes/0
ype of Project/ Activity A le yorS ' i. e f W/
b ' x 16
I
13'
(Scale: )VTS
Shoreline Length t nZ �1
4ccess Length
p
3ier (dock) length
=ixed Platform(s) 10,J(
P� (/-V�
-
=loafing Platform(s)
11
NAC 1�tX 13t
�.l�nCI-it
singer pier(s)
rota) Platform area 1 6CJS�n
3roin length/#
3ulkhead/ Ripraplength P'
%vg distance offshore
3reakwater/Sill
�
vlax distance/ length
3asin, channel
:ubicyards
lat�I ` lei !Y,jk
10�
3oat ramp
I r
k 13
3oathouse/ oatlift
3each Bulldozi
ether
1
;AV observed: yes nor'
Aoratorium: Ion) s no r
N
%�
Site Photos: ye no
r
1
f Cp
f _
tiparian Waiver Attached: Le no
'WJ
% building permit/zoning permit maybe required by: �_�.tl�`1G C
1Y�A��i
4�Z
❑ TAR/PAM/NEUSE/BUFFER (circle one)
i C1( -V r tS
ermittonditions ! J��S /li�l n.,--Qa'�►or'=,
Fa +G e! Sl/i,I.
-
❑ See note on back regarding River Basin rules
See additional notes/c;ndifrk
AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial
gen r Applicant PRINTED Name
ignature "Please read compliance statement on back of permit"
93,31
plication Fee(s) Check #/Money Order
Signature
i(V -IS-
�I-�--
Issuing Date Expiration Date

All.
t)wnry lir�r►ur•;Ilny f r�rn�ll /, % /�
Ntlmr• id 1 nil , ' / / � f
Z�5�'
7`�---
phor7e Number:
-ford
Ernail Address: y1/l�t,/��
f that I have authorized _ a fi -- --f " — ggent / Contractor
I certr y ermits
to act on my behalf, for the purpose of applying for and obtaining
all CAMA p
necessary for the following proposed development:
,.,U. o 0
at my property located at
K t
/ Coun Y.
�n rant permission to
rant, and do in fact g nd their agents to enter
/ furthermore certify that / am authorized the Local Permit officer nformation related to this
Division of Coastal Management staff,
on the aforementioned lands in connection with evaluating
per application.
Property owner Information:
Signature
M ` K& iTi4-y—e ,�i
Print or Type Name
Title
Date
This certification is valid through / �----

kSTDEMENT AIVER FORM
N G DIVISION OF CO/WNE L M)y FICA110NJW �
PROPERTY OWNER NO cr fiAsl�1_L1��""'"
ADJAGENIEU irARIAN r�F2N RT Glrss - 1-RE�� J_i
Lt1 completed by owner or their agent)
(Top portion to be comp t
Nwme of f'mperty owner —
N"
Address of Property
Madm4 Address of owner v
rf owner's Phone#
Owner email: Agent Phone#: 25 J 3;1
�itrch/'
Agent's Name (4 i
Agent's Email'
ADJACENT RIPARIAN PROPERTY OWNER'S
CERTIFICATION
(Bottom ortion to be com leted bv the Adjacent Pro ertv owner i I in for this
The individual apply
g
the development they are proposing A
I hereby certify that I own property adjacent to the above referenced property.
permit has described to me, as shown on the attached drawing,
descri tion or drawin with dimensions must be rovided with ltDOletter.
have objections to this proposal
I DO NOT have objections to this proposal.
you must notify the N.C. Division of Coastal
respondence should be
K you have objections to what is being proposed,
Management (DCM)
in writing within 10 days of receipt o27909n DCM representatives Ives can also be
mailed to 401 S. Griffin St., Ste. 300, Elizabeth City, NC,
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 u must sign
(this does not apply to bulkheads or riprap revetments). (If you Wish �je the setback, yo
the appropriate blank below)
I DO wish to waive some/all of the 15' se
Signature of Adjacent Ri rian 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 of ARPO: f ,�
Mailing Address of ARPO:
ARPO's em if: t� �� �i`�ma� l'om ARPO's Phone#:
Date: *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

i understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, ooamuu
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
I to bulkheads or riprap revetments). (If you wish to waive the setback you musign
this does not app y st
the appropriate blank below )
I DO wish to waive some/all of the 15' setback ,Lj /,J_
Signature of Adja ent Riparian Pro rty Owner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO:
Mailing Address of ARPrO::
ARPO's email: W� c�1 ' .0 ARPO's Phone#: ' y�4 �� �i�'�
Date: kA 2U41 `waiver is valid for up to one year from ARPO's Signature'
Revised July 2021

Construct a new 40' X 5' walkway to a 10' X 16' platform

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