86413A_Mattern, Warner & Brown, Verna_20211115

'Jto"rk ACAMA ❑ DREDGE & FILL 0- N° 86413 A B C D
MAJ
GPrevious permit
GENERAL PERMIT L_
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:
I SA NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.Yov/CAMArules
Applicant Name _
Address
City
Phone # (_ )
Email
State ZIP
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
P
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
(Scale: )
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 buildin ermit/zonin
ermit ma
be re uired b
gP gP Y q Y•
Permit Conditions ❑ 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 dr Applicant PRINTED Name Permit Officer's PRINTED Name
r
Signature **Please read compliance statement on back of permit** Signature
Application Feels) Check #/Money Order Issuing Date Expiration Date

Name of Property Owner Requesting Permit ✓yaf� e w a I (J�r�a� /'�/O`�
Mailing Address:
Addrm:
U y scof f- L artr.' ar} -,e--
Qs q - `(dL(- oho L,j
certif,► thart l nave aluthori�ed L �}yD�N M i Z'f' P-,
Agent 1 Ccn#acW
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
neaessaay for the ftlowing proposed devetOpmenc 7o Cb ^sS n,�
at my property loomed at to i 5co-f 4 t 10
in "oAl',- County.
I furthermore cer* that ! am audw&ed to grants and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and therm agents to enter
on the sibm nenhoned fends in connection with evaluating information related to this
Penn# aw -
Ai" Ary
srgnanre
P►i # or Type Name
b w,.reA
Title
This cerfiflc am is valid through I_t'50_1 44

N.C. OMSION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTiFlCATIONIWAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property • tt u 4togAi
Address of Property: _( ��T t_�a t� ? �.� z.a h (r i i"ri'� .0 Z. �iO4!
Mailing Address of Owner: say" P_
Agent's Name:
4 , + ►ra 1Wr'ft-JTP•
Agent Phone#
Agent's Email
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIMATION
(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 dirnensiom must be provided with this letter.
_X' . 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 wiring within 10 days of receipt of this notice_ Correspondence should be
mailed to 401 S Griffin St, Ste. 300, Ehzabeth Chit', NC, 27M DCM s can also be
contacted at [phone]. No response is considered the same as no objection if you have been
notified by Certified Mari_
WAIVER SECTION
I understand that any proposed pier, dock, mooring pings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of 16 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' setbaci: C��— —" �—*
Signature of Adjacent Riparian PtopeWOwner
OR -
I do not wish to waive the IS setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner.
Typed/Printed name of ARPO:
Mailing Address of ARPO:
ARPO's email: ARPO's Phoned:
Date:
'waiver is valid for up to one year from ARPO's Signat u e*
Revised May 2021

14 VI-110
P�vg�/ma +

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)
r. !' Name of Property Ownema//c. r-r K•A
Address of Property: lu 7 .'re)
Mailing Address of Owner.
Owner's email: T Y CZ; Cv r• x ,y Owner's Phone#:
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 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.
,Y"' 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
noted 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
-OR-
of jacent iparian Pr perty Owner
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

Pas uotank Count NC Nc �IaO9
q Y
1:564
�C' C �✓ ��. 0 0.01 0.01 0.02 mi
0 0.01 0,01 0.03 km
NC CGIA, Moxer, Mlaosofl

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Legend
104 Scotland Dr
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