86421A_Mattern, Warner & Brown, Verna_20211119

t°"r4,&❑CAMA ❑ DREDGE & FILL N9 86421 A B C D
8
Previous permit V
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.dgq.nc.gov/CAMArules
Applicant Name _
Address
City
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: 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
(Scale: )
❑ 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.
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature **Please read compliance statement on back of permit** Signature
Application Feels) Check #/Money Order Issuing Date
(Please Initial) _
Expiration Date

N 0 V ' 1 2021
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NOV'92021
DCM-EC
N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTiFICATIONIWAIVER FORM
CERTIRED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top Portion to be completed by owner or their agent)
Name of Property Owner_ a�e_ q +
Address of Property: %U 7( ZI�/✓✓C�
3.4
Mailing Amass of O ',/ /e•I , ✓
Owner's email: i.}� C-Z t-JC2 0 Owner's Phone#: (AA (,A (-
Agent's Name:
Agent's Emait
Agent Phme#7
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
I hereby certify that l own property adjacent to the above referenced property_ The individual applying for this
permit has described tD me, as shown on the attar drawing. the development they are proposing. A
description or draw na, with dimensions, must be provided with thL; letter_
,Y" I DO NOT have obiections th this proposal. I DO have objedions to this proposal_
fE you have oblecdons to what is being proposer, you nwst nobly the N_C. Division of Coastal
A"rayerrhent (DCM} in wNi V rriifarr 10 days tof retro(pt of tWs C.orrespondrenae should be
mailed to 401 & Cwh nn St, S116. 304 Efta6edi 04& NC, ZT9QA DCM can also be
contacted at (254 264-3907_ No response is conshhwed the same as no option if you have been
nothBed by Cerfifie+d Marl_
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set bads 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
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: ARPO's Phone#:
.*waiver is valid for up to one year from ARP(Ys Signature'
,), -7 00
Revised May 2021

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RECEME-ID
4 0 V 1 9 2021
N-C. DMISION OF COASTAL
ADJACENT FWARIAN MWERTY OWNER NOMFICATIONMAMER FORM r-%M-EC
CERTWIED MAIL - RETURN RECEIPT or HAND DELIVERY
(Top parfim to be cm~ by arm or #vek agent)
Naum of Properly f�&,OA-J
Address of PropWy- (W cScn-rLd,-A& 'b�- -C-L-Z-A&7)4 e,,i-V c , z- -?:Wj
Mating Addms-, of Owner &-
Owner's ernakIA6&t4C,f*APL-ei,� -Owner sPhonalt(
AgWs Name:
AgWs Enm*
AWd Phone#. -
ADJACENT RIPARIAN PROPERTY OWNER'S CERT11FIrATION
MgtoM portion to be 92MR12ftd by the AWmmt Property
I hereby certify that I am property ac@acent to the above referenced prop". The ffxkvodual appWmg for this
Pmd has described tD me. as shown an the attached drawkV. the devekpmeFd they are propomW A
description or drewom with cknensKwm mud be Provided with th:► letter.
X" . I DO NOT have o4echons to this PFOPOS81. I DO have o4ections flo this proposal -
If you ham objections to what Is being proposed, ym mast noffy the AM Dhftim of Coastal
Atanagement(DCAI)mmftngwhftslodays ofoeca*dofddshodcp- Correspondemm should be
stied 1b 401 & GdWm St, Ste. 300, Elizabeth Cft AF% 27M VCU repress deftes can also be
'. far fe dat(254 264-3M- No response is considmWillmsmseas no objectibn x7you have been
noMed by Certiffed MaL
I UnderstmW 1191 am pmposed tier dock. mooring - 19 bad 9MV6 brealowker. boaftesp- K or
groin mist be set beds a n*ikmm dfsaafce t* 16 room mV am of rQarien
=ess unless reinedby me(this does not apply to ImAdmcls or rqmW revdraerft(if you wish naive to ScdxK*, you must man
the appropriate 6iadc below-)
I DO wish to waive sonsehill of the 15 Q PH P I i
-OR- Somb" ofAdjqcer# Rpwm PmpeWOwner
I do not wish to waive the IS SeUX3ck mq*wnerd ("W the bkm*)
Skjnatme of Adjacent Riparian Property Owner
Typed4hkded name of ARPO:
Mailing Address ctARPO-
ARPO's email: ARP(Ys Photo--*.
Daft 'Waivew is valid for up to one year imm A&P-O's slim ture,
Revised May 2021

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