86688A - Cerveny, Kimberly

'4„®CAMA ❑DREDGE 8 FILL N. 86688 B C o
GENERAL PERMIT Previous permit Issued(j New FlModification ❑ Complete Reissue ❑ Partial Reissue
As authorized by the State of North Carolina, Department of Erniro menial Quality and the Coast Resotirm Commission in an area of errAronrtxmdl concern pursuant to:
I SA NCAC ' 19 CO Rules JIM00d. ® General Permit Rule+ available at cite followtrts link: www.
_�.4.4.IILywlCJII'1Attrles
Applicant NameLAuthorzed Agent OR Kd n^oCea "Side nLM►
Address Dr Q�dd i
Project Location (County): r
City E U10-bOK-, 94state W- zip 229 09 Street Address/Stte Roaal of I/(s) Id 1T It ZI
Phone ix (954) __33 i - 91t g
Finau2Y`V+2y%yl nr1%4Subdrvlslon
lu r Ed,rn4.-, ZIP a7Q3Z
Affected ❑ cthr ®Ew 5 PTA ❑ n PTs Adj. wtr Body P 16o-ar- L (S�o�..nA
��rmantt.,k)
(s): Elm ElIHA � uw ❑ sPIMA ❑ ms cios— Maj. wtr Body A 16c&-arkkre _
OR1N: veivPNA: ye;9
Type of Project/ Activity
o. 3' xCr t
Shorefine Length K)O r I �
Access length
qt l
Pier (dock) length Qt XS y
r
Fixed Plartform s)
Floating Platforms)
Anger piers)
Tout Platform area
Groiniength/8
i
Bulkhead/ Rlprap length
1
Avg distance offshore
i - -
Breakwater/sill
i -r--
Max distance/ length
1
Basin, channel
Cubic yards
r
Boat ramp .-
Boathouse/ Boatlift
,
Beach Bulldozing
i -
Other('
I
SAV observed: yes�'� !I 1T"_`-
Moratorium: yes I , , 1 .....f.. ►_.. T_ A—L
Site Photos: no _ ` _�7-' -' •-'r r-i—r-�— r
Riparian Waiver Attached:
A building permit/zoning permit may be required by: C /emu 1, Q yC,
Permit Conditions
THAT
Agent orApp�c PRINTED �ame
��// ttFF//11�� t `(` l Gi/�1�1
signature **Please read compliaWstatement on back of permit**
S 2a) - Qv- Sno 2q
Application Fee(s) Check a/Money order
I X `Or
(scale: 14'=3d)
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,
TAIWAM/NEUSMUFFM (circle on.)
See note on back regarding River Basin rules
11 See additional notes/conditions on back
AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
Permit _ cer's PRINTED Name,
wgnawre
7/22r�}-��-
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
dtnto� NC 2-133 7--
Phone Number: 25Z- 33ti- Ct l � 8
Email Address: �Mi?e(I�CP_r,��lly��gMQ� 1. corvt
I certify that I have authorized
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: �� 5` ��� w44i a
it
wpm �l6L+A {m and Zd 41o` atr��, a� +- x eAd o-� +he yjoL[ kway
wit Z Jet sue. I,�r` s
at my property located at ! t1 1 {eY, }-aq _ IQ a -�i fe Edenbe) N)(— 2-193Z
in _-- Cxlt) County
l furthermore certify that l 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.
Property Owner Information:
k/ME�LYCXEZT CE�I/ENy UCE
.0` fit a- I;;,RTER i:E wP-EN, .1 [Ut
Signature RECEIVED
KIMBERLY CARTER CERVENY AND BRUCE PECK
Print or Type Name J U L 0 7 2022
Title
Jun/22, 202?
Date
This certification is valid through I
0, CM -EC

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. Kim �y�t-1 `4` 6rucC- Per L
Address of Property: 11) 4er+ 4-a4e ) o'le-i t a+�'�
Mailing Address of Owner: 1
QC, 2"1`t3z
Owner's email: WCAlew lU2& Owner's Phone*. AS—33i-5iLS
Agent's Name: Milt n /�115J� ���+gent Phone#: ��— -
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property OWnel)
I hereby certify that I own property adjacentto the above referenced property. The individual applying forthis
permit has described to me, as shown on the attached drawing, the development they are proposing. 6
description or drawing with dimensions must be provided with this letter.
I DO NOT have objections to this proposal. I DO have objections to thi3 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 Malt.
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
-0R-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: Robert Keith Davis
Meiling Addroas of ARPO; PO Box 790, Marshall NC 28753
ARPO's email:
Date:
[e-mail] ARPO's Phone#: [phone]
Jul 6, 2022
'waiver is valid for up to one year from ARPO's Signature'
j U L 0 7 2022
t)cM-EC
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. Kim Ce eve n u `� &AcL rQ, c L
Address of Property: 112 R,*-r i IuQe Ro'n-f Drie_ 0L 2-.93;1
Mailing Address of Owner: l
1, (- 2-113 L
Owner's email: k1Cav-Wr 2p2lgpaAla,l �,,, Owner's Phone#: —331—gtta
Agent's Name{ SQ M1liAna jccmlySae ah{"prteAgent Phone* -2�- �5
Agent's Email _QV,�r�e5.3`d_e , C.QrAJYaG1bf aQ en-4—Ut .Dvn
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacent Property Owner}
1 hereby certify that I own property adjacentto the above referenced property. The individual applying for this
pemvt 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.
® 1 DO NOT have objections to this proposal. I DO have objections to thin proposal.
if you have objections to what is being proposed, you must notify 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 dprap 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
-OR-
I do not wish to waive the 15' setback requirement ('initial the blank)
4E1 V E®
PAA
J U L 0 1 2022
Signature of Adjacent Riparian Property Owner:
Ron & Pam Appelt
Typed/Printed name of A RPO:�
Mailing Address of ARPO: 10440 E Olivewood Dr Palmer AK 99645
ARPO's email: [e-mail] ARPO's Phone#: [phone]
Date: 1 July 2022 "waiver is valid forup to one year from ARPO's Signature'
Revised July 2021

a 0 1
Je+ s
6-m
DECEIVED
J U L 0 7 2022
DCM-EC

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Google Earth
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200 ft