86407A_Jardiniano, Matiyaga_20211103

Ito"►k ,[XCAMA ❑ DREDGE & FILL n t2 N9 86407 A B C D
s Previous permit
GENERAL PERMIT \`
Date previous permit issued
0 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:
15A NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: www.degnc.Qov/CAMArules
Applicant Name
Address
Citv
Phone #
Email
State ZIP
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yese PNA: yes/0
Type of Project/ Activity
Shoreline Length
Access Length
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Total Platform area
Groin length/#
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/Sill
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
SAV observed: yes no
Moratorium: n/a yes no
Site Photos: yes no
Riparian Waiver Attached: yes no
A building permit/zoning permit may be required by:
Permit Conditions
(Scale: )
o
i
❑ TAR/PAM/NEUSE/BUFFER (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)
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit" Signature
Application Fee(s) Check #/Money Order Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
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Mailing Address: `���/
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Phone Number:
Email Address:
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I certify that I have authorized 1-lin
Agent /
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: S /�' P i P�
at my property located at l l D� l- ► 3'
in Ili! County.
I furthermore certify that 1 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
permit application.
Property Owner Information:
Si ature ,/
a r i ot �,- c;\- �t - Jot
PH46or Type Name
Title
Date
This certification is valid through !- 1 1 / d l

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: -7 S /�a / v1 I-e V 1 tD 11Z L1 6 tIc-C Mailing Address of Owner
Owner's email: r t " // � '/�r _�^ (/ Owner's Phone#: —% 7 " 7 - -) �✓ �
Agent's Name: `C4r jCl&j /' 1y1 r •'1 C �h t- Agent Phone#: 05 3,� - &3L�
Agent's Email 10-9 a 60 //!4'1•'t n e
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-
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 Lo V ,�
Signature of AdjacentRiparian 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:
Mailing Address of ARPO:
ARPO's email:
Date:
ARPO's Phone#:
'waiver is valid for up to one year from ARPO's Signature'
Revised May 2021

I-C_ DWISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTI gCATIONNUAP4ER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top porition W be c by owner or tt� agent)
Name of Property Owner_ I'4 y Q -,� 'A. K - Ci Vt�,( 14 CL ft-6
Address of Property_
`�J
Mailing Address of Owner_ SGt At e —
Owner's emak f"k �}C irdi, r- Owner's Phoneme
AgPnrs Name la�,�f / �.-, c-�b4-
Agerit Phxx4t3
Agenrs Emait
-7S-`Jp6 n I e- i
jdc�
it
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(B__OUorn portion to be c onyieted by the Adiacent proomft Owner)
It z _
1 hereby certify that I own property adjacent to the above referenced property. The indsvkhmg applying for this
permit has described to me, as shown on the attached drawing, the development they are proposing. A
descrintion or drawing with dimenskm rruist be provided with this iet%er_
1 DO NOT have objections tit this proposaL ,, Do have objections to,this proposaL
If you have objections to what is being Proper you must not4fy the N.C. Division of Coastal
Management (DCY) in w ftb?g within 10 days of r of this nombe. ConaMmadence should be
mailed to 4W & Gnfrm St, Ste. 300, Elizabeth 044 NC, 2"M DCY iqxesedatiks can also be
contacted at rdS4 Zi64 M- Nb r gmnse is cwnkbred the same as no 04teUon x7you haws been
noffied by Certified Mail
I understand that any prgxwed pier, dock. mooring per. boat gip. breakwater bit, or
groin is be set back a mkninrm disiarroe of 19 from my area of riparian access unless vowed by me
(this does not apply to buWwads or riprap revehnemb). (lf you wish ID waive the sethadc, you must sign
the appropriate Mart below.)
I DO wish to waive somefall of the 15 setback _
-0R-
Stpiaftm ofA4acwi fi* wian Property Owner
I do not wish to waive the 16 setback requirement (infral the blank)
Signature of Acfcent Riparian Property Owner_
Typed/Pdnted nerve of ARPO--
IMaikng Address of ARPO:
ARPO's email:
Date:
ARPO's Ptx)rw#:
is valid for up to one year from ARPO's Vie'
Revised May 2021

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