86512A - Godfrey, Jr., Roy

(J0Mry ❑CAMA ❑ DREDGE & FILL N° 86512 A B C D
GPrevious 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: www.dgq.nc.Yov/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
(Scale:, )
Shoreline Length
Access Length
Pier(dock)length
Fixed Platform(s) Cs
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
Imo• _.
...._.
__
_
_
Boat
ramp
Boathouse/Boatlift J
Beach Bulldozing �� � ������� )� ° i
r.
� ! ` '
�i -T
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:
❑ 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)
r
Agent or Applicant PRINTED Naaryrymnne
Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit`*
Signature
Application Fee(s) Check #/Money Order Issuing Date Expiration Date

ECEIVED
MAR 2 1 2022
AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
DCM-EC
Name of Property Owner Requesting Permit:o.,
Mailing Address: -?- o 4>
Phone Number:
Email Address: t- o ti cx%x e-,/ 3 C CX4.—ri A, cO.'C.
I certify that I have authorized o-..I \—o, �.J
Agent / C or
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: s s i &
II)IV ID' olC4-k111I
at my property.located at LIL O PD«Ie V
in Nsr t4o447 A, County.
I 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.
ner infor
' nat
Print or Type Na
Qwr�r
Title
Date
This certification is valid through � l Is I �

RECEIVED
MAR 2 1 2022
N.C. DIVISION OF COASTAL MANAGEMENT 4?r, ,11-- E C
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: v `O i
Address of Property: "A1-kR ���'. Stc= �,',�-�c��s v e �\ x��n��. e ,�-� tJ •� • :V7
Mailing Address of Owner: 3-0Cow - ��> `Mo �.� ti C, D-'7q a
Owner's email: v-o 2S� ri. .\ •Owner's Phone#:
Agent's Name: ,gt4 t',-)�lL Agent Phone#: )�
Agent's Email: wi,�M
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 drawing, with dimensions, must be provided 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
Signature of Adjacent Riparian Property Owner
I do not wish to waive the 15' setback requirement (initial the blank) .
Signature of Adjacent Riparian
�Property
�Owner��d
Typed/Printed name of
Mailing Address of ARPO: \�o "� ;���\' ; ,, �t- • v
ARPO's email:
ARPO's Phone#: 75rj- 77� — G W 1 %
Date: _.3 - {,7 - �, L *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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RECEIVED
MAR 2 1 2022
N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM-N p /I _ E C
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY -✓
(Top portion to be completed by owner or their agent)
Name of Property Owner.
Address of Property:
Mailing Address of Owner: --116 '\J--3N�v C)�, V3
CGr-,-
Owner's email: Owner's Phone*
Agent's Name: 4f,&u'r14"r^g Agent Phone# 1� 5 33f �' 13
Agent's Email:
,sIC
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 development they are proposing. A
description or drawing, with dimensions must be provided with this letter.
I DO NOT have objections to this proposal. I DO have objections to this proposal.
ff you have objections to what is being proposed, you must nobly the N.C- Division of Coastal
Management (OCM) 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 sometall of the 15' setback
Signature of Adjacent Riparian 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 of ARPO:
Mailing Address of ARPO:
ARPO's email:
Date: ) i � - ZOLI. "waiver
4
ARPO's Phone#:
Ce-,r n
vulld for up to one year from AffVs Signature`
Revised July 2021
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RECEIVED -
MAR 2 1 2022
DCM-EC
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