86155A_Ward, Winfred & Vicky_20211118

1)144AMA [] DREDGE & FILL N9 86155 CA) B C D
Previous permit
GENERAL PERMIT Date previous perms issued
VNew ❑ Modification ❑ Complete Reissue ❑ Partial Reissue
As axhatzed br the
Scam of North Carobu. Department of Ertveorerw" Quaky and the Coed Resources Comrro wn in area of erwtroranettal concern purnant to:
I SA NCAC _..-qjt d L J' D Rries attached 5:&G-" %rFm Ruks avat"e at dre bbwehr&wwwdm
Appicant _e n� �_��_ W •L -- Auhonz'ed Agent _
---
Address - -- - ° u X --- _. _--- Prgect Locatiora (Cotrrrty):
ZIP L7 7. 3_ a Saeat Addimrstxe Row" i(s) Z_ o T 3
Plw *(I* (, Z[— if 71 s qt. Z. (, o /oa.c.:C�J � d j
Emai hA1 ua.1 t..ed 3� �� • �1� _ SuDdiriieon � R n d Q C
cashi-i!_ ZIP zip 3 (o
Affected ❑CW 6m 6PTA ES m A4.Wtr. Body
AEC(_} E � ❑l
❑NA uw ❑�► ❑� Closest Wtr. Body PCX^ / s
MP. d
O rel \ IONA res/no )
TbW of Ptoject/ J1tft" rl S ���� Z� X / L r c� l % r4- /t. *- g t f D X i 3 •-b -, I -
v- � (Scale: CID
Shoreiwe Lew*h Aarss tenth — G A J✓ A S J •,• aJ J N 1
Pier )deer) krqth
Feed Placlorer(s)
Floating Pbttorn A%l
APW pier(:)
Total Pladorm area
Gram kr*Wg
&*J- / pip as wwth
#04 distance onshore
breaknaw/Si —
Um distance/ lergth
Basel, daamrd —
Cubic yards —
Boat ramp ft.thpoMidt ></2
Beach Other
ft"w g
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s
A3Ht._ 1 1
SAV obwreed: ,� L' J C CO R I� ► Qy(� ' KNE)f os
kAoratonun: n/a yes 1'fS3s
Srte t,oe�: no W rt R V
ftipra7 Mrarrie► Aaathed: Yes ro
A �m pert/�1{ permit nW be
reew red by: a-rt C.k 4 h f
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❑ TANWIMEUSEMUFFER (vck one)
See rote on bade regardrrr ff RNer Basin rules
See additional notes/condmorn on back
I AM AWARE OF ST CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMEN*Pfease trtihaq
-4 Vj CIZ,, YV o i1 A Q- CO-" , f
or Ilppkun PRINTED Permit Officer's PRINTED Name
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nature -'Please read compliance a on of permit'• re
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AppYc— Feels) Check 0/Money Order IsUAN Date Eaprraton Date

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 age'nt)I,, � f -��
Name of Property Owner: In���d U,Ji' 5r, a11A '� I ck4 ` u TIl Er
Address of Property:wLo��Ct4-�S�ir�SCO�1�C�1�1J�o
Mailing Address of Owner: 1-�' may- �q , F r - s _ o Z % 73 (,P
Owner's email: 6A " 33�f`( dQP xy(Uwner'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 drawina. with dimensions. must be orovided 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 r i1
Signature of Adjacent Riparian Propert7'7wner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner: ! '/G
Typed/Printed name of ARPO: Dew l S& LCs6 l K G
Mailing Address of ARPO:
^'�_ w
ARPO's email: DPry LOSC�n ¢�1� 1 C ARPO's Phone#: p, j 5 (49
Date: /G_ , I -waiver is valid for up to one year from ARPO's Signature`
Revised July 2021

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U.S. Postal Service TIM
CERTIFIED MAIL@ RECEIPT
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Domestic Mail Only
Lee s b ur g VA 2017
r=1
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Certified Mail Fee
$3.75
$
7 7
Extra Services &Fees (check b , do fee a
[I Return Receipt
71]
C:3
(hardcopy)
❑ Return Receipt (electronic)
0)
mark
(:3
❑Certified Mail Restricted D vQV
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C-3
El Ad -It Signature Required $
E] Adult Signature Restricte $
M
Postage
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$
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Total Postage and Fees
1 fib ./2021
C3
Sent To AVV
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Street and Ajit No., or Pd Box No------------------------------------------------
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