86442A_Kelleter, Trey & Leigh_20211208

`°"r4,&❑CAMA ❑ DREDGE & FILL N9 86442 A B C D
go', GENERAL PERMIT Previous permit ✓
Date previous permit issued
❑ New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue
As authorized by the State of North Carolina, Department of Environmerntal 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.gov/CAMArules
Applicant Name Authorized Agent
Address Project Location (County):
City State ZIP Street Address/State Road/Lot #(s)
Phone # (_')
Email Subdivision
City ZIP
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
r
Access Length - — -
Pier (dock) length
Fixed Platform(s) F .
! A
Floating Platform(s) �^ µ
Finger piers);
e `
Total Platform area i rt
Groin length/# (' k
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/Sill
Max distant length
S }
Basin, Channel
Cubic yards ^ ° J
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
i'
SAV observed: yes no
Moratorium: n/a yes no . , '...
Site Photos: yes no - i
Riparian Waiver Attached: yes no,�
A building permit/zoning permit may be required by:
Permit Conditions
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( ': 4
(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. (Please Initial) c
Agent or Applicant PRINTED Name
Signature "Please read compliance statement on back of permit**
1q 0.)o. oo SA -)-
Application Fee(s) Check #/Money Order
Permit Officer's PRINTED Narrle
Signature
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permi-/S
Mailing Address:
3 3 `�
dk-P'-=". , U
Phone Number:
Email Address:
I certify that I have authorized SA4 N F—
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: D kE ba I t\ e
at my property located at C,l, t\i C 2 7 �,1 Z %
in l.UA 1 1 VC K County.
1 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:
Signature
Print or Type Name
Title
1�1 2,V /-
Date
This certification is valid through ( / 2O / ZZ

ServiceTM
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❑ Adult Signature Required $--j}j}fi" �i, I�</�
Adult Signature Restricted Dellvery $`
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1'6" 1'6" 2' 3' 4' 5'4" r 6'8" 6'8" TV 7'4"
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1'6" 1.8" 2" 3" 4" S'S" 7' S. 8'
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1'3" 1.91• 2'9" 4• 5' 6' 7'6" 8'
+ + + + + + + + + +
1' 1'6" 2' 3' 4'5" 6'5" 8' S. 8'+ 8'+
5' 1' 118" 3' 4'4' - 6'6" S. 8' 8'+ 8'+
757-y3°,-2835

N.C. DIVISION OF COASTAL MANAGEMENT MRECEIVED
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FOR
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
NOV 3-2021
(Top portion to be completed by owner or their agent)
Name of Property Owner: 7—PE-Y KF— L L E-T- F_ iZ DCM-EC
Address of Property: 5-0 (O IJ \ g4 . C , 2
n 7 / Z 7
Mailing Address of Owner: SI 3 ' NT � E _54_1"--,9 % VA- 23 3 Z -
Owner's email: -r-ks L L iT�R� � Dow er'sPhone#: 10q'ZZ(o"t
Agent's Name: S H)kN F- \) NTC a Agent Phone#: 75 7 - H 3 `� - Z8 3 s
Agent's Email: CA PS R 0 91 @ C0 X , tJ LT _
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
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 -OR-
C�-
Signature of Adjacent Riparian Property ner
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: (? 9 2 IJA-1711 ,e" r
ARPO's email: a/0170-c" Qirt(�v. cl,,^1 ARPO's Phone#: SOS `f 7 2 - 410 9 Z.
Date: Z01 30 JZd z I *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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ERed: Band_I
❑Green: Band_2
NBlue: Bad 3
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