Stevens, Kenneth 84636C

0 1*°E`°"Sr"1&c❑CAMA El DREDGE & FILL N9 84636i A B c D
y = 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:
15A NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name
Address
City State ZIP
Phone # (� )
Email
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
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 <t:
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
SAV observed: yes no'
Moratorium: n/a yes no
Site Photos: yes no - — !(` -�f.• r� rf
Riparian Waiver Attached: yes no j
f
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
ElSee 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 Feels) Check #/Money Order Issuing Date Expiration Date

1*�F`°"rNI ❑CAMA ElDREDGE & FILL Na 84636 A B C D
z 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: 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
Access Length—
Pier (dock) length f
Fixed Platform(s)
Floating Platforms)
Ginger pier(s� '
Total Pla7prtn area
Groin length/#
Bulkhead/ Riprap length } '-No
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 j
h
®�I�l■ miL31mmms
(Scale/
Site P otos. 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
ElSee 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 #/Money Order Issuing Date Expiration Date

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MAP FOR RECORD
SURVEY FOR

■ Complete items 1, 2, and 3. A. s r
■ Print your name and address on the reverse X _ ❑ Agent
so that we can return the card to you. ❑ Addressee
■ Attach this card to the back of the mailpiece, B. Rec 'v nt N e) C. ate of Delivery
or on the front if space permits. ��L �j "I/V
1. Article Addressed to: D. Is delivery address different from item 12 ❑ Yes
If YES, enter delivery address below: ❑ No
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9590 9402 6946 1104 1692 21
2. Article Number (Transfer from
7015 0640 0003 0995 3369
PS Form 3811, jury e-u�u . -. --
■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
brct Aun MQ-,�on
iOC
3. Service Type
❑ Priority Mail Express@
❑ Adult Signature
❑ Registered MajjTM
❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
❑ Certified Mail®
Delivery
❑ Certified Mail Restricted Delivery
❑ Signature ConfirmationTm
❑ Collect on Delivery
❑Signature Confirmation
❑ Collect on Delivery Restricted Delivery
Restricted Delivery
❑ Insured Mail
❑ Insured Mail Restricted Delivery
(over $500)
Domestic Return Receipt
A. Signature
X ❑ Agent
t M -164 ❑ Addressee
B. Received by (Printed Name) C. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
U
3. Service Type ❑ Priority Mail Express®
fI "IIIII IIII ICI I III I II II I I I I I I �I II' III I I II III ❑ Adult ❑ Restricted
Signature ❑ Registered MaIlTm
El Adult Signature Restricted Delivery Registered Mail Restricted
❑ Certified WHO Delivery
❑ Certified Mail Restricted Delivery ❑ Signature ConfirmationTm
9590 9402 6946 1104 1692 45
❑ Collect on Delivery ❑ Signature Confirmation
2. Article Number (transfer from service label) ❑ Collect on Delivery Restricted Delivery Restricted Delivery
nsured Mail
7 015 0 6 4 0 0003 0995 3376 sured Mail Restricted Delivery
-v_ er $500)
PS Form 3811, July 2020 PSN 7530-02-000-9053 Domestic Return Receipt
■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
A. Sirne
❑ Agent
X
❑ Addres
B'Re ceived by tinted Name) C. Da of elie
�4
D. I elivery address different from item ? ❑ s
If YES, enter delivery address below: ❑ No
d
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3. Service Type
❑ Adult Signature
❑ priority Mail Express®
❑ Registered IVExpr
allTm
❑ Adult Signature Restricted Delivery
❑ Certified Mail(D
❑ Registered Mall Restricted
Delivery
9590 9402 6946 1104 1692 38
❑ Certified Mail Restricted Delivery
❑ Signature Confirmation-
2. Article Number (Transfer from service label)
❑ Collect on Delivery ❑ Signature Confirmation
❑ Collect on Delivery Restricted Delivery Restricted Delivery
7015 0640 0003 0995 3383
isuredMall
isured Mail Restricted Delivery
wer $500)
PS Form 3811, July 2020 PSN 7530-02-000-9053
Domestic Return Receipt I

'ff
l=Icarua E oneoce &'F!LLrGENERIqL PERMIT
lNew lModification f]Complete Reissue E Partial Reissue
As authorized by the Sate of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
l5ANcAcf]n,u.attached.l-lGeneratPermhRulesarrailableatthefollowinglink:www.deq.nc.8ov/CAMArules
N9 84636 ABCD
Previous permit
Date previous permit issued
Applicant Name Authorized Agent
Addrurt proiect Location (County):
City State ztP Street AddresVState Road/Lot #(s)
Subdivision
ztP
Phone#(_)
Email
City
Affected
AEC(s):
ORW: yes/no
!cw
OEA
E.t
Iserrvrr
E"rt
!ews
EW
IHA
PTA
UW
Adj. Wtr. Body
Closest Mai. Wtr. Body
PNA: yes/no
Type of Projectl Activity
(Scale: )
Shoreline Length _
Access Len6h
Pier (dock) lengh . r"
Fixed Platform(s) _
Floating Platform(s)
Total Platform area
Groin length/# --
Bulkhead/ Riprap length _
Avg distance offshore .
Breakwater/Sill
Max distance/ length
Basin, channel _
Cubic yards _
Boathouse/ Boatlift _
Beach Bulldozing
Other
SAV observed:
Moratorium: n/a
Site Photos:
Riparian Waiver Attached
yes no
yes no
yes no
yes no
j
4
Abuildingpermit/zoningpermitmayberequiredby:
Permit Conditions ! raVeaNlNEUsE/BUFFER (circte one)
[-l S"" note on back regarding River Basin rules
See additional notes/conditions on back
I AM AWARE OF CRC RULES AND CONDITIONS THAT APPLY TO TH COMPTIANCESTATEMENT. (Pleaselnitial)
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature ++Please read compliance statement on back of permittr Signature
Application Fee(s)Check #/Money Order lssuing Date Expiration Date
tr
tr
Finger pier(s) _
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Statement of Compliance and Consistency
This permit is subject to compliance with this application and permit conditions. Any violation of these terms may
subject the permittee to a fine or criminal or civil action; and may cause the permit to become null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for
compliance. The applicant certifies by signing this permit that: 1) prior to undertaking any activities authorized by this
permit, the applicant will confer with appropriate local authorities to confirm that this project is consistent with the
local land use plan and all local ordinances, and 2) a written statement from the adjacent riparian property owner(s)
has been obtained, or proof of delivery of certified mail notification of the adjacent riparian property owner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and beliel certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Neuse River Basin Buffer Rules
lf indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules
for the River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the
NC Division of Water Resources. lf you have any questions, please contact the Division of Water Resources at the
Washington Regional Office (252-946-6481) or the Wilmington Regional Office (910-796-7215).
Notes/Additional Permit Conditions:
Please ensure all debris associated with the removal or construction of the permitted development is contained within the authorized
project area and disposed of in an appropriate upland location,
Dlvision of coastal ManaEement offices
Morehead City Headquarters
400 Commerce Ave Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST Fax: [phone]
(Serves: Carteret, Craven - south of the Neuse River, Onslow
counties)
Elizabeth Oty District
4O1 S. Griffin St. Ste. 300
Elizabeth City, NC 27909
252-264-3907
(Serves: Bertie, Camden, Chowan, Currituck, Dare, Gates, Hertford,
Pasquotank and Perquimans Counties)
WashinBton District
943 washington Square MallWashington, NC 27889
252-946-6481
Faxj. 252-948-047I
(serves: Beaufort, craven - north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext. Wilmington, NC 28405-3845
970-796-7275
Fax:[phone]
(Serves: Brunswick, New Hanover and Pender Counties)
http://portal.ncdenr.org/web/cm/dcm-home Revised 6/01/2021
Tar - Pamlico River Basin Buffer Rules
"olryfuEcanna E oReocE & FtLu ra ri e q
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As authorized by the Sate of North Carolina, Depanment of Environmental Quality and the Coasal Resources Commission in an area of environmental concern pursuant to:
l5ANcAc!nrrrcsatacnea.!ceneratPermitRrrhsarrailabhatdrefollowirrglinkwww.deq.nc.8ov/CiAMArules
N9 84636 ABCD
Previous permit
Date previous permit issued
Applicant Name
Address
City State ztP
Authorized Agent
Project Location (County):
Street AddresVState Road/Lot #(s)
Subdivision
City
Affected
AEC(s):
ORW: yes/no
Er* lrmlrm Ir*
PNA: yes/no
cw
OEA SPIMA
Irrt
!rws
ES Adl. Wtr. Body
Closest Mal. Wtr. Body
Type of Proieal Activity
Shoreline Length _
Access Length _.--
Pier (dock) length _
Fixed Platform(s)_
(Scale: )
fL
T*
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1
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Avg distance offshore _
Breakwater/Sill
Max distance/ length _
Basin, channel
Cubic yards _
Boat ramp
Boathouse/ Boatlift _
Beach Bulldozing
Other
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SAV observed:
Moratorium: n/a
yes no
yes no ?-ff-1Site Photos: yes no
Riparian Waiver Attached: yes no
A building permit/zoning permit may be required by:
Permit Conditions TARIPAI'I/NEUSUBUFFER (circle one)
See note on back regarding River Basin rules
See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RUTES AND CONDITIONS THAT TO THIS PROJECT AND REVIEWED COMPTIANCE STATEMENT.(Please lnitial)
Agent or Applicant PRINTED Name Permit Officert PRINTED Name
Signature +tPlease read compliance statement on back of permit*i Signature
Application Fee(s)Check #/Money Order lssuing Date Expira6on Date
Phone#(-)-
Email
ato
t
+-\
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\L
&Total Platform
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Statement of Compliance and Consistency
This permit is subject to compliance with this applicafion and permit condifions. Any violation of these terms may
subject the permittee to a fine or criminal or civil action; and may cause the permit to become null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for
compliance. The applicant certifies by signing this permit that: 1) prior to undertaking any activities authorized by this
permit, the applicant will confer with appropriate local authorities to confirm that this project is consistent with the
local land use plan and all local ordinances, and 2) a written statement from the adjacent riparian property owner(s)
has been obtained, or proof of delivery of certified mail notification ofthe adjacent riparian property owner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Neuse River Basin Buffer Rules
lf indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules
for the River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the
NC Division of Water Resources. lf you have any questions, please contact the Division of Water Resources at the
ce (252-946-6481) or the Wilmington Regional Office (910-796-7215).
&)
e e
+
a.
Notes/Additional Permit Conditions:
Please ensure all debris associated with the removal or construction of the permitted development is contained within the authorized
project area and disposed of in an appropriate upland location.
Division of Coastal Manarement Ofnces
Morehead City Headquarte6
400 Commerce Ave Morehead City, Nc 28557
252-808-2808/ 1-8884RCOAST Fax: [phone]
(Serves: Carteret, Craven - south of the Neuse River, Onslow
Counties)
Elizabeth City District
401 S. Griffin St. Ste.300
Elizabeth City, NC 27909
252-264-390t
(Serves: Bertie, Camden, Chowan, Currituck, Dare, Gates, Hertford,
Pasquotank and Perquimans Counties)
Washington District
943 Washington Square Mall Washington, NC 27889
252-946-6441,
Fax:[phone]
(serves: Beaufort, Craven - north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext. Wilmington, NC 28405-3845
970-796-7275
Fax:[phone]
(Serves: Brunswick, New Hanover and Pender Counties)
http://po rta l. ncden r.org/web/cm/dcm-home Revised 6/01/2021
Tar - Pamlico River Basin Buffer Rules
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PS Form 381 1, Juty 2o2o psN 7s3o-02-ooo-9050 Dom6tic Return R6c6lpt ,
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Tax Parcel Information Carteret County, N.C.
OTyneT: STEVENS,HELEN D ETVIR KENNETH
Current PIN: 747rooS5124Sooo
Site Address:
16TzHWY Zo STACy
STACY
Mailing Address:
T88 ASHLEY DUNCAN T-ANE
SEVFN SPRINGS NC z8Sz8
Legal Description:
ACREAGE HWYTo STACY
Prior PIN: o4oo3oo212
City Limits:
Rescue Dishict: SEA LEVEL RESCUE
Fire District: STACy FIRE
Tax District: 4
Torvnship: STAC!
Use: COI\INIERCIAL
Land Value: NBHD: 4ooo1
Bldg value, uldg Htd Sq Ft: 3384
Bldg Tot Sq Ft: o
Other Value:
Year Built: rg5g
Total Value: Noise Level:
Sale Price: AlCUZZonez
Deeded Acres: 3.517 GIS Acres: z.gg7
Plat Ref: / Roll Type: R
Deed Ref: 1727 / 43 Deed Date: zozro6rg
Bedrooms: o Bathrooms: l
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Printed February 23, 2022
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Tax Parcel Information:Carteret County, N.C l{
Prinied Febru'ary 23,2:,022r in=r87 ft
Orvner: HILL,PEGGY JO
Current PIN: 747roo5516zrooo
Site Address:
1686 H\4IY Zo STACY
STACY
MailingAddress:
rzzz COUNTRY CLUB DRIVE
ORI-{NDO FL 328o4
Legal Description:
LOT HWY Zo STACY
Prior PIN:
City Limits:
Rescue District: SEA LEVEL RESCUE
Fire District: STACY FIRE
Tax District: 4
Torvnship: STACY
Use: VACANT
Land value: NBHD: 4ooo1
Bldg Htd Sq Ft:
BldgValue:Bldg Tot Sq Ft: o
other value: Year Built:
Total Value: Noise Level:
Sale Price: AlCUZZone:
Deeded Acres: r.o88 GISAcnes: r.rr9
Plat Ref: / Roll Type: R
Deed Ref: tt58 I gS Deed Date: o
Bedrooms: Bathrooms:
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The nlqrratron disdayed by this websae is
nformation souces stptld be cmsdted for be
**CERTIFIED MAIL - RETURN RECEIPT REQUESTED**
March 7,2022
Division of Coastal Management
400 Commerce Avenue
Morehead Ciry, N.C. 28557
RE: Adjacent Property Waiver Form
Dear Sir or Madam,
Enclosed you will find the Adjacent Property Waiver Form that I received from a Mr. Jarvis Cox
on March 4,2022, indicating that an adjacent property owner wishes to make changes to their
property. I am objecting to this proposal as frankly, I have no idea what the property owner is
proposing to do. I am also enclosing copies of all that was included in Mr. Cox's letter so that
you can see that, though a description of the proposed changes is mandatory according to the
form and highlighted, none was included.
If you have any questions regarding this correspondence, please contact me in writing.
Peggy J.
r222 Club Drive
Orlando, FL 32804
cc: Mr. Jarvis Cox
enc.
RECEIVED
MAR i 4,?02?
DGM.MHD CITY
(';\s v CERTIFIED MAIL . RETURN RE CEIPT REQUESTED
11,w O c s5g
(Lot or Street #,treet or Road, City &nty)
Agent's Name #:
Agent's phone #
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 developmenl
they are proposing. A description or drawinq, with dimensions. must be provided with this letter.
I have no objections to this proposal
proposal.
I have objections to this
lf you have oblectlons to whet is belng proposed, you must notw the Dlvlslon of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
malled to tllD Commerce Ave., Moreheed City, NC, 28557. DCM representatives cen also be
contactad at [phone].IVo response is considered the same as no objection ffyou have been
notlfted by Ceftlfied Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15'from my area of riparian access unless waived by me. (lf you
wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement
(Property Owner lnformation)(Adj r tnformatil0M-MHD Clfy
Signature
Print or Type Name Print or Type Name
l1/1/y U DK
Mailing Address
Ip
RECEIVED
R 14 Z02Z
d
Mailing Address
0rt \lrlt ot
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERW OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
L' l"
Address of Property:
Mailing Address:
_K
\1(!
\\
\ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
\acentto P" rn, J-, [4, I I '"I hereby certify that
property located at
I own property adj -----:M;e of Proptt,Owner)
Le,,' ia 6 R,-e t ress, Lot,loc d, etc.)
on tn 1{, N.C(Waterbody) (Gity/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15'from my area of riparian access unless waived by me. (lf you
wish to waive the setback, you must initial the appropriate blank below.)
I do not wish to waive the '15' setback req uirement
(Pro Owner lnformation)Owner lnformation)
Signature Signature VV\ {I Vl/
Print or Type Name Print {1\w bI) K
Mailing Address ,",,,rntff!ffir,1,fi, l'vbl rt
City/State/Zip
Telephone Number Telephone Number (l'1.Yt)
(
Dale Dale
x
DESCRIPTION ANO/OR DRAWING OF PROPOSED DEVELOPMENT
(lndividual proposing development must fill in desc ption below or attach a site drawing)
I do wish to waive the '15' setback requirement.
City/Statez.ip
RECEIVED
(Revised 6n ar#Afl t I,t IZZ
DCM-MHD CITY
(\,.rd(,I
4t
^,1 CERTIFIED MAIL . RETURN RECEIF
DIVTSION OF COASTAL MANI
ADJACENT RTPARIAN PROPERTY OWNER NO'
kdu'D trrat u
-7k Rv ls u^
?le*se L*il rr\ r
Z h+,,e ,\ buyrA
4 ta1 v{+Pt, {,hu y
y, ,, x P *o p"*+y
7n0-v{s Cax
JSJ -}LTI^ q DqD
Name of Property owner: PuJg) *" il ; I
At,r, ar- nru llrrr2r!.!f,frr?r?"r1,Dl Ctt,t4 6-Nre
#:
I hereby certify that I own propefi adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing-the development
lidy'"r6 proposing. A description or drawino. with dimensions. must be provided with this letter.
I have no objections to this proposal. I have objections to this
proposal.
tf you have objectlons to what is being proposed, you.must notify the Divislon of Coastal
Minag"^ent pbq in writing within rc aiys of receipt_of_this notice. Correspondence should be
maileld b 40b Commerce ive., Morehead City, NC, 28557. DCM representatives can also be
contacted at (252) g}g-2g1g. Alo respons e is considered the same as no obiection if you have been
notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15' from my area of riparian access unless waived by me. (lf you
wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Signature
(Property Owner lnformation)(Adjacent Property Owner lnformation)
Signature
Pint or Type NamePrint or Type Name
RECEIVED
MAR 14?-O2Z
Mailing Address Mailing Address
DCM-MHD CITY
\'t
ADJACENT RIPARIAN P ROPERTY owN ER STATEMENT
Pn S
me of Prope rty Owne r)
property located at o
Le*,'a CR,-ek'
dress,Lot,d, etc.)
on .tn N.C
(Waterbody)(City/Town and/or CountY)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSEO DEVELOPMENT
(lndividual proposing development must fitl in description below or attach a site drawing)
WAIVER SECTION
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of l5'from my area of riparian access unless waived by me. (lf you
wish to waive the setback, you must initial the appropriate blank below.)
Sigaature
(Propefi Owner lnformation)(Adjacent Propefi Owner lnformation)
Signature
Pint or Type Name
Mailing Address
City/State/Zip
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number Telephone Number H ECEIVED
MAR 14 2022DateDate
6eviseaf((fffiD crry
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tuis+,
I hereby certify that I own property adjacent to
+