86429A - King, Todd

tA d "rM ❑CAMA ❑ DREDGE & FILL �(� N° 86429 A B C D
Previous permit 1�
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:
I SA 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 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.
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" o!CC
enature
SZd Z
Application Fee(s) Check #/Money Order Issuing Date
(Please Initial)_
Expiration Date

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFtCAT10NIWAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner. l 0 U 4 e.-
Address of Property: 130 Bfvj' 1 o /?-,- (2 D
L �a
Malting Address of Owner:
Owners email: %f /A Owner's Phone#:
Agent's Name: �y�(o!�_ 1� f1'i /1 L Agent P me#:_ l &3 1-�
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 attadted drawing. the development they are proposing. A
NOT have objections to this proposal. I DO have objections to this proposal.
K you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCAt) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Grdrn St, Sbe. 300, Elizabeth City, NC 27909 DCU representatives can also be
contacted at (252) 264 Ml- 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 revelments)_ (If you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15 setbac�
of Acokent Riparian /Property Owner
-0R-
I do not wish to waive Hie 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*.
Date: *waiver is valid for up to one year from ARPO's Signature*
Revised May 2021

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N.C. Dt\/ISIONI OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTFICATIONMIAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by/ _owner or their agent)
Name of Property Owner I b �J' ► T
Address of Prop": [ �, D BGt/..SG1 d
Mailing Address of Owner _ J `t L, / ► . Ly' l Gl v C%
Owner's email: f % s Phone#:
Agent's Name- L4(q&f3_ L- Agent Phone: �''
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 develWnent they are proposing. A
pddescri tion or drawffm. with dimenskm must be pmvided with this letter.
cv 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 nobly the N.C. Division of Coastal
Management (DCAQ in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Gntfin SC Ste. 300, Elizabeth City, NC, 27909. DCM nepreseyttativcan also be
contacted at (252) 264Ml_ No response is consi timed the same as no objection if you have been
notified by Certified Marl_
WAIVER SECTION
I understand that any proposed pier, dock, moorng pfrtgs, 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_)
1 DO wish to waive some/all of the 15' setbacik /
cIA06W Ro i an Property Owner
-OR-
I do not wish to waive the 1 & setback requirement ('utitial the blank)
Signature of Adjacent Riparian Property Owner.
Typed/Printed name of ARPO:
Mailing Address of ARPO:
ARPO's email: ARPO's Phone#:
Date: *waiver is valid for up to one year from ARPO's Signature*
Revised May 2021

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