86121A_Powell, Robert N_20211028

`°"rkN❑CAMA 0 DREDGE & FILL �� N9 86121 A' B CD
3° V
Previous permit
GENERAL PERMIT Date previous permit issued
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.deq.nc.2ov/CAMArules
Applicant Name _
Address
City
Phone # (_ )
Email
State ZIP
Affected ❑ CW ❑ EW ❑ PTA
AEC(s): ❑ OEA ❑ IHA ❑ UW
ORW: yes/no PNA: yes/no
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
❑ ES ❑ PTS
❑ SPIMA ❑ PWS
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Adj. Wtr. Body (nat/man/unk)
Closest Maj. Wtr. Body
(Scale: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

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front i ace permits.
1. Article Ad ressed to: f
Z o? � '0 ; sIle11 at spa
9590 9402 7056 1225 5572 14
2. Arti - f-- —rvice label)
7020 2450 0000 2566
A. Sig at s
X Agent
i �❑ Addre
B. eo Ived bvlMntetlJ9fime C. iDatJ of e�
D. Is delivery address different from item i? ID Y&
If YES, enter delivery address below: ❑ No
3. Service Type
Cl Priority Mall Express®
❑ Adult Signature
O Registered Mail*"'
❑ Adult Signature Restricted Delivery
O Reeggistered Mail Restric
❑ Certified Mall®
Delivery
❑ Certified Mail Restricted Delivery
❑ Signature Confirmation'
❑ Collect on Delivery
❑ Signature Confirmation
❑ Collect on Delivery Restricted Delivery
Restricted Delivery
r-1 Insured Mail
9235 tcted Delivery
PS Form 3811. July 2020 PSN 7530-02-000-9053 Domestic Return Receio

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: / 1/ - / d / /
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Address of Property: 2Z �
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Mailing Address of Owner:
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Owner's email: I-N,�rv�iaen,-,_� &ner's Phone#: Z'S i - -Z
Agent's Name: Agent Phone#:
Agent's Email:
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
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. 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
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 f Adj c nt iparian Property Owner
-OR-
do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:4 a [4
Typed/Printed name of ARPO: 14, c U Lf/[ _,1_
Mailing Address of ARPO: 221PR, &&,,sho►rn 1(�o279a9
ARPO's email: �1 T�6cthrrParn :/•<em ARPO's Phone#: c3_Q2-<2C7 -95'262
Date: waiver is valid for up to one year from ARPO's Signature*
Revised July 2021
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