Fordham, Wendell 84652C

"❑CAMA ❑ DREDGE & FILL Nn 84652 A B C D
3 GENERAL PERMIT Previous 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: wwwdeq nc gov/CAMArules
Applicant Name _
Address
City
Phone # (_ )
Email
Authorized Agent
Project Location (County):
ZIP 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
(Scale: )
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SAV observed: yes no
Moratorium: n/a yes no
Site Photos: yes no
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A building permit/zoning permit may be required
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.
i
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit" Signature -
(Please Initial)
Application Feels)
q/Money Order Issuing Date
Expiration Date

.0 Vombil ❑CAMA El DREDGE & FILL N° 84652 A B C D
Previous permit
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: wwwdeg2C.gov/CAMArules
Applicant Name _
Address
City
Phone # (_ )
Email
Affected ❑ CW ❑ EW ❑ PTA
AEC(s): ❑OEA ❑IHA ❑UW
ORW: yes/no PNA: yes/no.-
Type of Project/ Activity
ZIP
ES
❑ PTs
❑SPIMA
❑7
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Adj. Wtr. Body_
Closest Maj. Wtr. Body
ZIP
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(Scale:
Pier (dock) length
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A building permit/zoning permit may be required by:
❑ TAR/PAM/NEUSE/BUFFER (circle one)
Permit Conditions
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 or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit" Signature'
Application Fee(s) Check fJ/Money Order Issuing Date Expiration 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 agent)
Name of Property Owner: J l edjr, l
Address of Property: 1&1� 5oo-0-i KiO✓ 1— 01— de 292D42
Mailing Address of Owner: 5 S5" Li ✓G R) .;
Owner's email:f�/>�imhl�.7rtc,Y .Owner'sPhone#:
Agent's Name:
Agent's Email:
Agent
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
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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 400 Commerce Ave., Morehead City, NC 28557. 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
EaqPf (�� Q/rrr1f(Lki
Signature of Adjacent Riparialh Property Owner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name ofARPO: RCtsEer i,[ 5RIDCES
Mailing Address ofARPO: 3(,,eA KeN r1CINr1gt: RD, t_AN(NDALC ABC
ARPO's email• wnynemon470gmoil.rarr)ARPO's Phone#: 91G P9l 4470
Date: 4 ` 7 22 *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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)
Name of Property Owner: /i)1102z
Address of Property: 16.0 Sir1� �I✓G/' � i�P�z �2�/ � Z�rr/�
Mailing Address of Owner: SF._ 5S 4VeF c � ('%,�A �� 1n�n� n )C' 2 7�7fi
Owner's Phone#: _ Jq •gIS-CJ/rid
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 forthis
permit has described to me, as shown on the attached drawing, the development they are proposing. A
DO NOT have objections to this proposal. I DO have objections to this proposal.
lflobu 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 400 Commerce Ave., Morehead City, NC 28557. 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
1 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 of Adjacent Riparian Property Owner
No
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name ofARPO: ZLM,CLq— '/ CRi s+'hillGY'
Mailing Address of ARPO: 3 )- fiita I A) c ZS&C
ARPO's email: 'it-sihA1.14d4i � �i �r ARPO's Phone#: 70 $/ - Z 90 ZY16
Date: V4 2,- *waiver is valid for up to one year from ARPO's Signature`
� RECEIVED
Revised July 2021
APR 11 2022
DCM-MHD CITY

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