HomeMy WebLinkAbout84479C - Aragona, Beny.. A B M7 a
DREDGE & FILL
`. Previous permit f._...........
17' GENERAL PERMIT
Ctearevic��s porn it issued _........ .-r :"................_.._.w. _
New U C` odiflcation F] Complete Reissue [_] ParCiai Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursoant to,
t SA NCAC .__ _ 6 .......... .... .w__ Rules attached. } General Permit Rules available at the following link wvyw deq roc �;�vf�At��rules
Applicant Narne � %� _ .._._ ....,.._._.. _...
Address ......-....'" G- _
City t L- -6�— State ** „zip _
Phone # 41a) 33n
Email
Authorized Agent:
Project Location (County): ��
....._ __._._.,........._ ._.,...._ _...................
Street Address/State Road/Lot #(s) _� ._ � � ._.. �� _............
Affected EW '7A i S PTS A.di, wtr. Body _ �� "�' - n -tan/unk)
AEC(s); C3EA IH L1VU E] SP1MA PW5 Closest Maj. Wtr. Body � � 1���"
Type of Project Activityi 1 t i
(Scale: Itt`''�}� )
Shoreline Length. 11
1 t
Access Length
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
i V
Fin or pier(s)
- .....,.._ y
Total Platform area......# `�� � �-'`'" � � �r�r' -� �y t� c-
ron length/# _ tJ
Bulkhead/ R prap length
Avg distance affshore _-.-" ....................__..._....__
Breakwater/Sill
Matt distance/ length --"`-
Basin, channel
Cubic. yards _
Boat rarnp._. _
Boathouse/ Boatlift.._...._.........._........
Beach u ldozin�_----
Other
SAV observed: yes
Moratorium: nJa yes
Site Photos: Yes '
Riparian Waiver Attached: yes
A building permit/zoning permit
V
�4
w
/F Jtf�
,3y be required by; Ojt6cpto
4
............ _
sJu
TAR; PAMINEUSE/BUFF R (circle one)
See note on back regarding liver Basin rules
ElSee additional notes/conditions on back
CAMA ❑ DREDGE & FILL N9 84479 A B jt!� D
y =GENERAL PERMIT Previous permit
Date previous permit issued
[XNew ❑ 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 / K �f I ��y ❑ Rules attached. General Permit Rules available at the following link: www.deq_nc.jzov/CAMArules
Applicant Name ` /" "py�
Address �),�, ��/ ^0r(RG L,)
City AD"U f "6r State _ ZIP
Phone # ft) , 72 T
Email
fl-
Authorized Agent b ii� AaC
Project Location (County): 69JU6LOW
Street Address/State Road/Lot #(s) � o) I
Subdivision
City sn fwV ZIP
Affected CW EW PTA KES ❑ PTS Adj. Wtr. Body / G V v �"� V — Chat)nan/unk)
AEC(s): OEA IHA UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body V(--
ORW: yes,(t) PNA:D/no
Type of Project/ Activity AV16--Q— N hTiOW i1N1 7 1,J
(Scale:
Shoreline Length 0
Access Length �iI
Pier (dock) length ( )(IE"\
Fixed Platform(s)T? �
Floating Platform(s) f
Finger pier(s)
.,r
Total Platform area,
Groin length/#
Bulkhead/ Riprap length
,
\� �`L4�k
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 `V J• _V�Q/
Site Photos: yes
Riparian Waiver Attached: yes no�c,.,� _
A building permit/zoning permit may be required by:��vy ���
Permit Conditions
I AM AWARE OF STATUTES. CRC
Agent or Applicant PRINTED Nam
0,0
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
M ,STp'-Vv 14� 11 ��O PIVIr
PefmiVOfficer.'s PRINTED Name
Signature "Please read compliance statement on back of permit"
06 1---1 Z
Application Fee(s) heck Money Order
Sigmfur � 1 ❑ ^^
Issuing Datk Expiration Dat
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 belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
1-1 Tar - Pamlico River Basin Buffer Rules 1-1 Neuse River Basin Buffer Rules
If 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. If 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.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST Fax: 252-247-3330
(Serves: Carteret, Craven — south of the Neuse River, Onslow
Counties)
Elizabeth City District
401 S. Griffin St. Ste. 300
Elizabeth City, NC 27909
252-264-3901
(Serves: Bertie, Camden, Chowan, Currituck, Dare, Gates, Hertford,
Pasquotank and Perquimans Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Washington District
943 Washington Square Mall Washington, NC 27889
252-946-6481
Fax: 252-948-0478
(Serves: Beaufort, Craven — north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext. Wilmington, NC 28405-3845
910-796-7215
Fax: 910-395-3964
(Serves: Brunswick, New Hanover and Pender Counties)
Revised 6/01/2021
�\ 510.85
� E=2 468,462.62.42
\ �so
a �s s.
fz5F
N=3 \ 67,480.09
E-2,46B,416.97 \
\
P\
Rev. 08/01/22 JRK - Move pier head toward shoreline \
Rev. 07/20/22 KHW - Add new surveyed Coastal Wetlands and ANHWL lines per CAMA delineation, revise pier location.
Rev. 11/21/18 KHW - Revise pier and pilings
Rev. 07/16/18 JJS - Revised pilings on south side per owner
Rev. 06/28/18 JJ5 - Revised pier d piling locations per owner
GPS Grid North
O
NAD 83, 2011 Adjustment 00
NNW F
�P
Le end
Ac. - Acre�jr
ANHWL - Approximate Normal High Water Line / / j �j
BG - Below Ground / 0�. 0
O Comp. - Computed
D.B.- Deed Book / / / / TOECHANNEL
E - Easting /
GL - Ground Level
O IPF - Iron Pipe Found
O ISF - Iron Stake Found
M.B.- Map Book
N - Northing
Pg. - Page
O RISF -Reference Iron Stake Found
R/W - Right-of-way /
s.f.- Square Feet
[ ) - Distance to Reference Iron / � x (-)5.8
` 2 ; - Adjoiner lot Number
O- Lot Number / / x (-)5 S /
— • — • - — - 404 Wetlands Line / /:}P
Coastal Wetlands Line / x (-)15.3
a /
x (-)6.3
/ n
/ X /
/ x /
8' Center
Pier Detail
Scale: Not to Scale
(Provided By Mueller & Pittman, Inc.)
Field Book: New River Place, Pg. 18
Disk Nome: Acad #2665
Filename: NRP-Lott ExhlbiLdvvg JRK
Job No.: S220413-8085
/ 585°24'21'W
i— 5.35'
/ x (-)5.4
x (-)4.8
o/
x (-)3.8
ZIS68*12'031W
/x(-�.e
x (-)•A
-See
Inset
�P'11A CARD ,,,
�O .bFEssro4�y9 ;
SEAL
14575
River Exhibit Map
Notes:
1. No Visible Submerged Aquatic Vegetation or Shellfish.
2.(-)4.8 Represents The Typical Relative Water Depth Below
Normal Low Water at its Location.
3. -4.2 Represents The Typical Relative Landward Height
Above Normal Low Water at its Location.
4. THESE ARE NOT ELEVATIONS. NLW is Per Field
Observation. Water Depths and Landward Height Shots are
Adjusted to NLW. Equal to 0.0.
5. Boundary, Elevations, and Edge of Channel taken from
survey/plan done in 2013.
6.404 Wetlands Delineated by Pittman Soil Consulting:
and Surveyed by Parker 6 Associates, Inc. on 07/18/13.
7. Coastal Wetlands Line and ANHWL delineated by Curt Weychert
6-14-22 and surveyed by Tidewater Associates, Inc.6-21-22.
S. No Register of Deed Search Done by or Furnished To
Surveyor Regarding Deed or Covenant Restrictions.
9. The GPS portion of the boundary work was performed to
third order, Class I, FGCC specifications, The coordinates
were obtained by Real Time Kinematic Differential GP5
Observations using Trimble Survey Grade 5800 GPS Unit,
NCG5 RTK Network Adjustments to NC Grid NAD' 83,
2011 Adjustments.
10. All distances are horizontal ground, U.S, survey feet.
11. All acreage calculated by coordinates.
12. Any portion of boardwalk or pier going over Coastal Marsh
area shall be a minimum of 3' above ground to bottom of pier
supports.
NEW RIVER PLACE
LOT i
"x6" Deck Board Jacksonville 7wp., Onslow Co., North Carolina
Developer:
Ben Aragona, Sr.
5/8' Bolt 112 Scientific lane
Jacksonville, North Carolina 28540
(910) 330-2237
DATE- 05/21/18 GRAPHIC SCALE: 1-=30'
0 10 20 30 60 90
SCALE: 1"c30' FEET
TIDEWATER ASSOCIATES, INC.
Consulting Engineers - land Surveyors - Land Planners
Jacksonville, North Carolina
P.O. Box 976 - 306 New Bridge Street - 28540
Phone (920) 455-2414 - www.riidowaterENC.com Est. 1961
Firm License Number. F-0108
N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date April 21 , 2022 \�
q� t-js�ls Z�m
Name of Property Owner Applying for Permit:
BEN ARAGONA, SR.
Mailing Address:
112 Scientific Lane
Jacksonville, NC 28540
I certify that I have authorized (agent) Timothy M. Stewart, P.E.
to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) Dock, Pier and Lift
at (my property located at) Lot 1, New River Place (201 Leonard Street), Jacksonville, NC
This certification is valicl-,thru (date)
Property Owner Signa4'ure
4 - a I -a a-.
Date
RECE-1VED
APP 2 5 2022
DC -MHD CITY
CAMA / ❑ DREDGE & F1 `yea 72358 A B C
GENERAL PERMIT Previous permit #
W-11ew
El Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality i �
and the Coastal Resources Commission in an area of environmental concern pursuant to ISA NCAC -- �� r
C-`Rules attached.
Applicant Name / � &VAI i- Project Location: County t-5- , "%(.d 1 __ _ _
Address _ � � ,4,/- C- '� - _ - Street Address/ State Road/ Lot #(s)
City PAS PCVF- State/!. ' ZIP
Phone # J")./A07F �d.E-Mail Subdivision _
Authorized Agent '%ttrvf7L�_-_ City��'�'1���� ZIP
CW (�W 9OPTA VS ❑ PTS Phone # q-i�) !- River Basin//4t ale. Affected D OEA ❑ HHF ❑ IH ❑ USA ❑ N/A if ;;e, nat m f3 L nkn)
AEC(s): Adj. Wtr. Body _ -_-
ORW: yes no PNA yes no
Closest Maj. Wtr. Body ._ _ y✓- _.____ _ ____ 1
� f -� t �
Type of Project/ Activity���� _---�<`��.�' l�' � _ �
�. (State:
Pier (dock) length,-6_. _ _� _ _. �r �_ - -- •/".
Fixed Platform(s)
Floating Platform(S)
t
Finger piers)
Groin 7T)b
h , l -J—
? 1
J,
Bulkhea Rlprap length
l i j
0
avg dl arise offshore
max dis rce offshore
Basin, channel
cubic yards t + r ) !
-
_......__
Boat ramp-
�� i
Boathouse/ Boatlift
f
i i
Beach Buildozing..... _ - _ ;
Other - fi
I
...
!
i
Shoreline length _
SAV: not sure yes�l-
+
2
Moratorium: n/a yesao
Photos: yes 1 I i e
Waiver Attached: es-)
A building permit may be rreeq--aired by: U,5F ❑ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction) ,
Notes) Special Conditions � /"i � � Ike
I P _..�-
Aden or Applica t inred Nar a Per fist s Printed Name
l ature e e e r d co pli ce stitement on back of permit * Signatur
----— -
. ... .... TY
a
Application Fee(s) Check # Is ui ng D ate Expiration Date
TIDEWATER ASSOCIATE'S, INC.
IF
EST 1961 JACKSONVILLE, NORTH CAROLINA
VIA MAIL April 22, 2022
Mr. Curt Weychert
Division of Coastal Management
400 Commerce Avenue
Morehead City, NC28557
Re: Lot 1, New River Place
CAMA General Minor Permit
Application
Dear Mr. Weychert,
The following information is being submitted to you to obtain a CAMA General Minor Permit for
a Pier and Dock. A Permit was previously issued 12-3-18. It was never constructed, but now the Owner
is ready to construct it. Please find enclosed:
1) One (1) copy of the previously issued Permit.
2) One (1) copy of the River Exhibit Map showing the proposed pier.
3) One (1) signed Agent Authorization Form.
4) One (1) Adjacent Riparian Property Owner Statement Form signed by Troy Tuton.
5) One (1) Adjacent Riparian Property Owner Form that was sent to Doug Hemby by Certified
Mail. Also attached is the Certified Mail Receipt.
6) One (1) copy of each Certificate of Documentation for 36' and 43' boats.
7) One (1) check for $200.00 for the review fee.
If you have any questions or need any additional information, please let me know.
Enclosures
ec: Mr. Ben Aragona (w/enclosures)
xc: CF (P) LAM
TMS/djh
C 1.2022.FORMS.ARAGONA-NRP I . WEYCHERT.NCDEQ.CAMAPERMIT.041422
Sincerely,
TIDEWATER ASSO IA , I C.
Timothy M. tew, , P.E.
RECEIVED
APR 25 2-022
306 New Bridge Street I P.O. Box 976 I Jacksonville, NC 28541-0976 I (910) 455-2414
Firm License Number F-0108 I www.tidewaterenc.com DCM-MHD CQTY
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: BEN ARAGONA, SR.
Address of Property: LOT 1, NEW RIVER PLACE, ON 201 LEONARD STREET
Mailing Address of Owner: 112 SCIENTIFIC LANE, ,JACKSONVILLE, NC 28540
Owner's email: cace@bizec.rr.com
Agent's Name: Timothy M. Stewart, P.E.
Agent's Email: office@tidewaterenc.com
Owner's Phone#: (910) 330-2237
Agent Phone#: (910) 455-2414
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.
S7 1 DO NOT have objections to this proposal. I DO have objections to this proposal.
It 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 (252) 808-2808. 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 AdjacentYlp
arian Property Owner
-OR-
do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner.
Typed/Printed name of ARPO: STEPHEN TROY TUTON
Mailing Address of ARPO: 205 LEONARD STREET, JACKSONVILLE, NC 28540
ARPO's email: troytuton@me.com ARPO's Phone#: (910) 934-3981
Date: �C. o
*waiver is valid for up to one year from ARPO's Signature* ,
Revised July 2021
7 r
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U.S. Postal Service TM
CERTIFIED MAIL® RECEIPT
Domestic mail Only
For delivery information, visit our website at www,,._-
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Adult Signature Required $ --4. 1 ❑-44❑ —1
Adult Signature Restricted Delivery $
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Postmark
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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: BEN ARAGONA, SR.
Address of Property:
LOT 1, NEW RIVER PLACE, ON 201 LEONARD STREET
Mailing Address of Owner: 112 SCIENTIFIC LANE, JACKSONVILLE, NC 28540
Owner's email: case@bizec.rr.com Owner's Phone#: (910) 330-2237
Agent's Name: Timothy M. Stewart, P.E.
Agent's Email: office@tidewaterenc.com
Agent Phone#: (910) 455-2414
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 400 Commerce Ave., Morehead City, NC 28557. DCM representatives can also be contacted
at (252) 808-2808. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
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:
Typed/Printed name of ARPO: DOUGLAS HEMBY
Mailing Address of ARPO: 180 LEONARD STREET, JACKSONVILLE, NC 28540
ARPO's email: ARPO's Phone#:
Date: *waiver is valid for up to one year from ARPO's Signature*
Revised July 2011
WED
APR 2, 2022
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: BEN ARAGONA, SR.
Address of Property:
LOT 1, NEW RIVER PLACE, ON 201 LEONARD STREET
Mailing Address of Owner: 112 SCIENTIFIC LANE, JACKSONVILLE, NC 28540
Owner's email: case@bizec.rr.com Owner's Phone#: (910) 330-2237
Agent's Name: Timothy M. Stewart, P.E.
Agent Phone#: (910) 455-2414
Agent's Email: office@tidewaterenc.corri
Postal
CERTIFIED MAIL@ RECEIPT
ADJACENT RIPARIAN PROPERTY OWNED Domestic
(Bottom portion to be completed by the Adi m •
I hereby certify that I own property adjacent to the above referenc
permit has described to me, as shown on the attached drawin, .1
description or drawing with dimensions. must be provided with - o
I DO NOT have objections to this proposal. I c3
0
If you have objections to what is being proposed, you rr C3
Management (DCM) in writing within 10 days of receipt of; C3
mailed to 400 Commerce Ave., Morehead City, NC 28557. DC a
at (252) 808-2808. No response is considered the same as r C3
Certified Mail. o-,
r�
WAIVER SECTION �0.
I understand that any proposed pier, dock, mooring pilings, boE
groin must be set back a minimum distance of 15' from my are,
(this does not apply to bulkheads or riprap revetments). (If you wisl
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Atach this card to the back of the mailpiece,
or on the front if space permits.
1. A:rticle Addressed to:
Mr. Douglas Hemby
180 Leonard Street
Jacksonville, NC 28540
Jf1 cgrr` l ` i M 240
;ertitied Mall Fee
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❑ Return Recut (h$ _1, , I�111
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❑ Return Receipt (electmnlc) $ - $Lf l : l tli
❑ Certified Mall Restricted Daywy $ t�� � I (
Postm A
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®Adult Signature Required $
El Adult Signature Restricted Delivery $
tage
1.44
0te1P®Mr. Dqu !has Hemby 08Jb2/2022
e�tTo 180 Leonard Street
treaii0acksonville, NC 28540
A. Signature
.I].,/Agent
X !�_ •t, tr t_ �,tldressee
B. Received by (Printed Name) Date of Delivery
Sj -2��
D. Is delivery address different from ite 1? ❑ Yes
If YES, enter delivery address belo : p No ��nn
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3. Service Type
❑ Adult Signature
❑ Priority Mail Express@
❑Registered MaiIT"'
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❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
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El Certified WHO
Delivery
❑ Certified Mail Restricted Delivery
` A Return Receipt for
❑ Collect on Delivery
Merchandise
2. Article Number (Transfer from service label)
;
-1 Collect on Delivery Restricted Delivery ❑ Signature ConflrmationTM
7 019 0160 0000 0868
1636 estricted Delivery
❑ Signature Confirmation
Restricted Delivery
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt
• r r,
:Owner
A pECEIVED
AUG 10 ?-022
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: BEN ARAGONA, SR.
Address of Property:
LOT 1, NEW RIVER PLACE, ON 201 LEONARD STREET
Mailing Address of Owner: 112 SCIENTIFIC LANE, JACKSONVILLE, NC 28540
Owner's email: case@bizec.rr.com
Agent's Name: Timothy M. Stewart, P.E.
Agent's Email: office@tidewaterenc.com
Owner's Phone#: (910) 330-2237
Agent Phone#: (910) 455-2414
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.
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 (252) 808-2808. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
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.)
DO wish to waive some/all of the 15' setbaol1
Signature of Adf�'cent Riparian Property Owner
-OR-
do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
RECEIVE
Typed/Printed name of ARPO: STEPHEN TROY TU- 61N ncNAHD CI
Mailing Address of ARPO: 205 LEONARD STREET, JACKSONVILLE, INC 28540
ARPO's email: troytuton@me.com
ARPO's Phone#: (910) 934-3981
Date: *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021
N 10.85
i
2,468 462.
E=2 468,46242
2a,
its,. ✓� Q'� ''s
4sF
W 36
367,485.09
E=2,468,416.97
\
\
2ev. 08/01/22 JRK - Move pier head toward shoreline
2ev. 07/20/22 KHW -Add new surveyed Coastal Wetlands and ANHWL lines per CAMA delineation, revise pier location.
2ev. 11/21/18 KHW - Revise pier and pilings
2ev. 07/16/18 JJS -Revised pilings on south side per owner
2ev. 06/28/18 JJS -Revised pier 6 piling locations per owner
GPS Grid North
NAD'83, 2011 Adjustment
Legend
/
Ac. - Acre /
ANHWL - Approximate Normal High Water Line /
B6 -Below Ground /
0 Comp. - Computed
D.B. - Deed Book
/ / TOECHANNEL
E - Easting
GL - Ground Level
0 IPF - Iron Pipe Found
0 ISF - Iron Stake Found
/ /
M.B. -Map Book
N - Northing
Pg. - Page
O RISF -Reference Iron Stake Found
/
R/W - Right-of-way
s.f. -Square Feet
/ v
[ ] - Distance to Reference Iron
� 2 i - Adjoiner Lot Number
L; .
O- Lot Number /
x (-)5.5 /
aoa wetlands Line
- Coastal Wetlands Line / /
/
X (-)5.3 / v
e
/
X (-)6.3
/ x
/
8• Center
n,.., T-1-s-,.:1
Scale: Not to scale
{Provided By Mueller 6 Pittman, Inc.)
Field Book: New miter Place, Pg.18
Disk Name: Aced #2665
Filename: NRP-Lott Exhibitdwg JRK
Job No.: S22C413-8085
/
/
/ SS85°24'21"W
/ �-- 5.35'
ro
-SPA x (-)4.e
o/
/
/
/ S68°12'03"W X (')4•e
�2.41'
X (-NA
,mp
See
Inset
0
11,1 a 111„,�'
�OPoVA CAR
F ss 9:
SEAL =
14575 _ $-ol' IV
�110111;41"1",
River Exhibit Map
Notes:
1. No Visible Submerged Aquatic Vegetation or Shellfish.
2. (-)4.8 Represents The Typical Relative Water Depth Below
Normal Low Water at its Location.
3. -4.2 Represents The Typical Relative Landward Height
Above Normal Low Water at its Location.
4. THESE ARE NOT ELEVATIONS. NLW is Per Field
Observation. Water Depths and Landward Height Shots are
Adjusted to NLW. Equal to 0.0.
5. Boundary, Elevations, and Edge of Channel taken from
survey/plan done in 2013.
6.404 Wetlands Delineated by Pittman Soil Consulting:
and Surveyed by Parker S Associates, Inc. on 07/18/13.
7. Coastal Wetlands Line and ANHWL delineated by Curt Weychert
6-14-22 and surveyed by Tidewater Associates, Inc. 6-21-22,
8. No Register of Deed Search Done by or Furnished To
Surveyor Regarding Deed or Covenant Restrictions.
9. The GPS portion of the boundary work was performed to
third order, Class I, FGCC specifications, The coordinates
were obtained by Real Time Kinematic Differential GP5
Observations using Trimble Survey Grade 5800 6PS Unit,
NCGS RTK Network Adjustments to NC Grid NAD' 83,
2011 Adjustments.
10. All distances are horizontal ground, U.S. survey feet.
11. All acreage calculated by coordinates.
12. Any portion of boardwalk or pier going over Coastal Marsh
area shall be a minimum of 3' above ground to bottom of pier
supports.
NEW RIVER PLACE
LOT 1
"x6" Deck Board Jacksonville iwp., Onslow Co., North Carolina
Developer:
Ben Aragona, Sr.
5/8" Bolt 112 Scientific Lane
Jacksonville, North Carolina 28540
(910) 330.2237
DATE: 05/21/18 GRAPHIC SCALE: 1"=30'
0 10 20 30 60 90
SCALE: 1"=30'
FEET
TIDEWATER ASSOCIATES, INC.
Consulting Engineers - Land Surveyors - Land Planners
Jacksonville, North Carolina
P.O. Box 976 - 306 New Bridge Street - 28540
Phone (910) 456-2414 - www.riidewaterENC.com
.���.� V1VC11otl lxumver. rwauc
■ 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,
nr nn the front if ennne norm,;+,
1. rvucid t%uureSSea 10:
i Douglas Hemby
208 Leonard St.
;lacksonville, NC 28540
1111111
Jill
1111111111111
11111
-�v. Z�U''3�V� � nature
`'Adult Signature
0 Priority Mail ajIT11 s®
❑Registered Mail
O Adult Signature Restricted Delivery
VCertified
❑ Registered Mail Restricted
9590 9402 5391 9189 2700 77
Mail®
Delivery
O Certified Mail Restricted Delivery
❑ Return Receipt for
Collect on Delivery
Merchandise
2. Article Number (Transfer from service label)
❑ Collect on Delivery Restricted Delivery ❑ Signature ConfirmationTM
7 019 0140 0001 0231 9134
❑ Insured Mail
jil Restricted Delivery
❑ Signature Confirmation
Restricted Delivery
verred
PS Form 3811, July 2015 PSN 7530-02-000-9053
—
Domestic Return Receipt
r-q
M
r1J
iD
rq
i�
r�
rq
3ostal ServiceTM
TIFIFn uaii ® PF=n r-
Domestic Mail Only
For delivery information, visit our website at www.usps.co:7
Viall-ej 6 6
uwsTRACKING #
111111 First -Class Mail
Postage & Fees Paid
USPS
Permit No. G-10
9590 9402 5391 9189 2700 77
unwam.
United States
Postal Service
• Sender: Please print your name, address, and ZIP+4® in this box*
Division of Coastal Management
400 Commerce Avenue
Morehead City, NC 28557 *�Vv
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
BRAXTON DAVIS
Director
Douglas Hemby
208 Leonard Street
Jacksonville, NC 28540
Mr. Hemby,
NORTH CAROLINA
Environmental Quality
I am writing to you regarding your objections to the proposed development at the address
201 Leonard Street, in Jacksonville, NC, Onslow County. We received an adjacent riparian
notification form on August 15, 2022. Can you please provide your reasoning through a
written objection within 10 days of the receipt of this correspondence.
If no written objection is received the Division will proceed with the processing of the
aforementioned proposed development.
Thank you for your time in this matter,
Respectfully,
Curt Weychert
NC Division of Coastal Management
Field Representative
D,.EAj
Department of Environmental 0"4
North Carolina Department of Environmental Quality I Division of Coastal Management
Morehead City Office 1 400 Commerce Avenue I Morehead City, North Carolina 28557
252.515.5400
1p ) 0 JD A (y_S 9
AD
N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVE- G 01
RY 1
Otiti
(Top portion to be completed by owner or their agent)
Name of Property Owner:
Address of Property:
BEN ARAGONA, SR.
LOT 1, NEW RIVER PLACE, ON 201 LEONARD STREET
Mailing Address of Owner:
112 SCIENTIFIC LANE, JACKSONVILLE, NC 28540
Owner's email: case@bizec.rr.com
Agent's Name: Timothy M. Stewart, P.E.
Agent's Email: office@tidewaterenc.com
Owner's Phone#: (910) 330-2237
Agent Phone#: (910) 455-2414
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
01a1�
ENO
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 atra"Z_15ed drawing, the development they are proposing. A
description or drawing, with dimensions must be
I DO NOT have objections to this propo al. �_ I DO have objections to this proposal.
If you have objections to what is being proposed, yo st notif the�NYC. Division al
Mana ement Dom) in writin within 10 days of receipt of this notice. pondence�souMe
mailed ed to 400 Commerce Ave., rehead Cit , NC 28557. DCM representatives can also be contacted
at (252) 808-2808. No response is considered the same as no objection if you have been notified by
.. . -- - x srwr
WAIVER SECTION
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 rvot appil y o u ea s or riprap revetmen s . (If you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setbackp
Signature of Adjacen iparian Rfoperty Owner
/V
.11,16
I do not wish to waive the 15' setback re uirement (initial the blank
bQQ
f Adjacent Ri aria Property Owner: �--•C
tignature o � p p y
TtJ yped/Printed name of AWPO: DOUGLAS HEMBY
',l' Mailing Address of ARPO: 180 LEONARD STREET, JACKSONVILLE, NC 28540 � c� ^R
ARPO's email: AL Z.�- ARPO's Phone#: Z V 14- r �
Date: ' *waiver is vaUd4er up-te--aneew fro_ rmn-44RP 's Siig�}nature*
{ —Revised July 2021
Weychert, Curtis R
From:
Tim Stewart <office@tidewaterenc.com>
Sent:
Tuesday, August 16, 2022 4:01 PM
To:
Weychert, Curtis R
Cc:
Ben Aragona,Sr.; Ben Aragona
Subject:
Re: [External] Re: New River Place, Lot 1
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Curt,
We don't have Mr. Hemby's phone number. Maybe Ben Aragona has it. You are probably going to have to knock on his
door if you want to talk to him.
I talked to him before when the permit was originally issued in 2018. He came by the office to ask how to fill out the
form to object it. He basically said that he does not want anything to be built anywhere near his property. I told him we
designed it to stay more than 15' off his riparian line, to meet the CAMA Rules, but he didn't care.
I think he is just anti -development or anti -everything.
Please let us know what the schedule for approval will be since he objected. Thanks.
Tim
Timothy M. Stewart, PE/djh
306 New Bridge Street
Jacksonville NC, 28540
910-455-2414 ext 106
TIDEWATER
ASSOCIATES, INC.
On 8/16/2022 3:21 PM, Weychert, Curtis R wrote:
Mr. Stewart,
Mr. Hamby filed an objection however did not provide us with a written description of what his
objectives were based on. I need to contact him in order to get clarification of what his concerns are
regarding this project. If you can please provide me with a contact phone number for him I can get in
touch and provide resolution on the proposed project.
Thank you,
Curt Weychert
1
Curtis Weychert
DCM Field Representative / Environmental Specialist II
North Carolina Division of Coastal Management
North Carolina Department of Environmental Quality
252-240-9497
Curt.Wevchert@ncdenr.gov
NORTH CARCLINA �/ /'
Uepartmmt of Environmental OuaNty
400 Commerce Avenue
Morehead City, NC 28557
http://portal.ncdenr.org/web/cm/dcm-home
E-mail correspondence to and from thus address may be subject to the North Carolina Public Records
Law and may be disclosed to third parties.
From: Ben Aragona <baaragona@gmail.com>
Sent: Tuesday, August 16, 2022 3:19 PM
To: Tim Stewart <office@tidewaterenc.com>
Cc: Weychert, Curtis R <curt.weychert@ncdenr.gov>; Ben Aragona,Sr. <cace@bizec.rr.com>
Subject: [External] Re: New River Place, Lot 1
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious
email as an attachment to Report Spam.
We need mr. Heavy number
Ben Aragona
910-358-2249
On Aug 16, 2022, at 1:41 PM, Tim Stewart <office@tidewaterenc.com> wrote:
Curt,
Just following up on this CAMA Permit. You indicated that it would be issued 10 days
after Mr. Hemby' received the Certified Mail. Please let us know the status. Thanks.
Tim
Timothy M. Stewart, PE/djh
306 New Bridge Street
Jacksonville NC, 28540
910-455-2414 ext 106
-------- Forwarded Message --------
Subject: Re: New River Place, Lot 1
Date: Tue, 9 Aug 2022 11:25:35 -0400
From: Tim Stewart <office@tidewaterenc.com>
To: Curt Weychert-NCDENR <curt.wevchert@ncdenr.gov>
CC: Ben Aragona,Sr. <cace@bizec.rr.com>, Ben Aragona Jr <baaragona@9mail.com>
Curt,
See attached scanned copies of the ARPO Notification/Waiver Form signed by S. Troy
Tuton along with a copy of the Certified Return Receipt showing documents received by
Mr. Douglas Hemby.
Please contact me if you need additional information or if you have any
questions. Thanks.
Tim
Timothy M. Stewart, PE/djh
306 New Bridge Street
Jacksonville NC, 28540
910-455-2414 ext 106
4
On 8/1/2022 4:53 PM, Tim Stewart wrote:
Curt,
Attached is a copy of the revised Plan. We will send to Adjacent
Property Owners tomorrow via Certified Mail.
Let me know if you need anything else. Thanks.
Tim
Timothy M. Stewart, PE/djh
306 New Bridge Street
Jacksonville NC, 28540
910-455-2414 ext 106
Virus-free.www.avast.com
Weychert, Curtis R
From: Tim Stewart <office@tidewaterenc.com>
Sent: Tuesday, August 16, 2022 4:01 PM
To: Weychert, Curtis R
Cc: Ben Aragona,Sr.; Ben Aragona
Subject: Re: [External] Re: New River Place, Lot 1
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Curt,
We don't have Mr. Hemby's phone number. Maybe Ben Aragona has it. You are probably going to have to knock on his
door if you want to talk to him.
I talked to him before when the permit was originally issued in 2018. He came by the office to ask how to fill out the
form to object it. He basically said that he does not want anything to be built anywhere near his property. I told him we
designed it to stay more than 15' off his riparian line, to meet the CAMA Rules, but he didn't care.
I think he is just anti -development or anti -everything.
Please let us know what the schedule for approval will be since he objected. Thanks.
Tim
Timothy M. Stewart, PE/djh
306 New Bridge Street
Jacksonville NC, 28540
910-455-2414 ext 106
TIDEWATER
ASSOCIATES, INC.
On 8/16/2022 3:21 PM, Weychert, Curtis R wrote:
Mr. Stewart,
Mr. Hamby filed an objection however did not provide us with a written description of what his
objectives were based on. I need to contact him in order to get clarification of what his concerns are
regarding this project. If you can please provide me with a contact phone number for him I can get in
touch and provide resolution on the proposed project.
Thank you,
Curt Weychert
Curtis Weychert
DCM Field Representative / Environmental Specialist II
North Carolina Division of Coastal Management
North Carolina Department of Environmental Quality
252-240-9497
Curt.Wevchert@ncdenr.gov
D_E
NORTH CAROLINA
Oepartrnent of Emrhomental Ouality
400 Commerce Avenue
Morehead City, NC 28557
http://Porta1.ncdenr.org/web/cm/dcm-home
E-mail correspondence to and from thus address may be subject to the North Carolina Public Records
Law and may be disclosed to third parties.
From: Ben Aragona <baaragona@gmail.com>
Sent: Tuesday, August 16, 2022 3:19 PM
To: Tim Stewart <office@tidewaterenc.com>
Cc: Weychert, Curtis R <curt.weychert@ncdenr.gov>; Ben Aragona,Sr. <cace@bizec.rr.com>
Subject: [External] Re: New River Place, Lot 1
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious
email as an attachment to Report Spam.
We need mr. Heavy number
Ben Aragona
910-358-2249
On Aug 16, 2022, at 1:41 PM, Tim Stewart <office a@tidewaterenc.com> wrote:
Curt,
Just following up on this CAMA Permit. You indicated that it would be issued 10 days
after Mr. Hemby' received the Certified Mail. Please let us know the status. Thanks.
Tim
Timothy M. Stewart, PE/djh
306 New Bridge Street
Jacksonville NC, 28540
910-455-2414 ext 106
----- Forwarded Message --------
Subject: Re: New River Place, Lot 1
Date: Tue, 9 Aug 2022 11:25:35 -0400
From: Tim Stewart <office@tidewaterenc.com>
To: Curt Weychert-NCDENR <curt.weychert@ncdenr.gov>
CC: Ben Aragona,Sr. <cace@bizec.rr.com>, Ben Aragona Jr <baaragona 9mail.com>
Curt,
See attached scanned copies of the ARPO Notification/Waiver Form signed by S. Troy
Tuton along with a copy of the Certified Return Receipt showing documents received by
Mr. Douglas Hemby.
Please contact me if you need additional information or if you have any
questions. Thanks.
Tim
Timothy M. Stewart, PE/djh
306 New Bridge Street
Jacksonville NC, 28540
910-455-2414 ext 106
4
On 8/1/2022 4:53 PM, Tim Stewart wrote:
Curt,
Attached is a copy of the revised Plan. We will send to Adjacent
Property Owners tomorrow via Certified Mail.
Let me know if you need anything else. Thanks.
Tim
Timothy M. Stewart, PE/djh
306 New Bridge Street
Jacksonville NC, 28540
910-455-2414 ext 106
Virus-free.www.avast.com
Weychert, Curtis R
From: Tim Stewart <office@tidewaterenc.com>
Sent: Tuesday, August 16, 2022 4:01 PM
To: Weychert, Curtis R
Cc: Ben Aragona,Sr.; Ben Aragona
Subject: Re: [External] Re: New River Place, Lot 1
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Curt,
We don't have Mr. Hemby's phone number. Maybe Ben Aragona has it. You are probably going to have to knock on his
door if you want to talk to him.
I talked to him before when the permit was originally issued in 2018. He came by the office to ask how to fill out the
form to object it. He basically said that he does not want anything to be built anywhere near his property. I told him we
designed it to stay more than 15' off his riparian line, to meet the CAMA Rules, but he didn't care.
I think he is just anti -development or anti -everything.
Please let us know what the schedule for approval will be since he objected. Thanks.
Tim
Timothy M. Stewart, PE/djh
306 New Bridge Street
Jacksonville NC, 28540
910-455-2414 ext 106
TIDEWATER
ASSOCIATES, INC.
On 8/16/2022 3:21 PM, Weychert, Curtis R wrote:
Mr. Stewart,
Mr. Hamby filed an objection however did not provide us with a written description of what his
objectives were based on. I need to contact him in order to get clarification of what his concerns are
regarding this project. If you can please provide me with a contact phone number for him I can get in
touch and provide resolution on the proposed project.
Thank you,
Curt Weychert
1
Curtis Weychert
DCM Field Representative / Environmental Specialist II
North Carolina Division of Coastal Management
North Carolina Department of Environmental Quality
252-240-9497
Curt.Wevchert@ncdenr.gov
Q.E �y/�)(/�
NORTH OAROLINA i'
Department of Envimnmeetel DuaNty
400 Commerce Avenue
Morehead City, NC 28557
http://portal.ncdenr.org/web/cm/dcm-home
E-mail correspondence to and from thus address may be subject to the North Carolina Public Records
Law and may be disclosed to third parties.
From: Ben Aragona <baaragona@gmail.com>
Sent: Tuesday, August 16, 2022 3:19 PM
To: Tim Stewart <office@tidewaterenc.com>
Cc: Weychert, Curtis R <curt.weychert@ncdenr.gov>; Ben Aragona,Sr. <cace@bizec.rr.com>
Subject: [External] Re: New River Place, Lot 1
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious
email as an attachment to Report Spam.
We need mr. Heavy number
Ben Aragona
910-358-2249
On Aug 16, 2022, at 1:41 PM, Tim Stewart <office@tidewaterenc.com> wrote:
Curt,
Just following up on this CAMA Permit. You indicated that it would be issued 10 days
after Mr. Hemby' received the Certified Mail. Please let us know the status. Thanks.
Tim
Timothy M. Stewart, PE/djh
306 New Bridge Street
Jacksonville NC, 28540
910-455-2414 ext 106
-------- Forwarded Message --------
Subject: Re: New River Place, Lot 1
Date: Tue, 9 Aug 2022 11:25:35 -0400
From: Tim Stewart <office@tidewaterenc.com>
To: Curt Weychert-NCDENR <curt.weychert@ncdenr.gov>
CC: Ben Aragona,Sr. <cace@bizec.rr.com>, Ben Aragona Jr <baaragona@gmail.com>
Curt,
See attached scanned copies of the ARPO Notification/Waiver Form signed by S. Troy
Tuton along with a copy of the Certified Return Receipt showing documents received by
Mr. Douglas Hemby.
Please contact me if you need additional information or if you have any
questions. Thanks.
Tim
Timothy M. Stewart, PE/djh
306 New Bridge Street
Jacksonville NC, 28540
910-455-2414 ext 106
On 8/1/2022 4:53 PM, Tim Stewart wrote:
Curt,
Attached is a copy of the revised Plan. We will send to Adjacent
Property Owners tomorrow via Certified Mail.
Let me know if you need anything else. Thanks.
Tim
Timothy M. Stewart, PE/djh
306 New Bridge Street
Jacksonville NC, 28540
910-455-2414 ext 106
V i r u s-free . www.avast.com
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: BEN ARAGONA, SR.
Address of Property:
LOT 1, NEW RIVER PLACE, ON 201 LEONARD STREET
Mailing Address of Owner: 112 SCIENTIFIC LANE, JACKSONVILLE, NC 28540
Owner's email: cace@bizec.rr.com Owner's Phone#: (910) 330-2237
Agent's Name: Timothy M. Stewart, P.E.
Agent's Email: office@tidewaterenc.com
Agent Phone#: (910) 455-2414
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adlaceat 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.
^J-.N .CD 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 (252) 808-2808. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
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' setbaol
Signature of Adj�l'cent Riparian Property Owner
-OR-
do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: STEPHEN TROY TUTON
Mailing Address of ARPO: 205 LEONARD STREET, JACKSONVILLE, NC 28540
ARPO's email: troytuton@me.com ARPO's Phone#: (910) 934-3981
Date:
*waiver is valid for up to one year from ARPO's Signature*
Revised Juiy 2021
DHS, USCG, CG-1270 (REV. 06-04) OMB APPROVED
. UNITED OF AMERICA 1625-0027
DEPARTMENT OF HOMELAND SECURITY
UNITED STATES COAST GUARD
NATIONAL VESSEL DOC[JMENTATION CENTER
CERTIFICATE 0FDOCUMENTATION
VESSEL NAME
OFFICIAL NUMBER
IMO OR OTHER NUMBER
YEAR COMPLETED
HARD LIQUOR
908856
1 NONE
UNKNOWN
HAILING PORT
HULL MATERIAL
MECHANICAL PROPULSION
JACKSONVILLE NC
FkP (FIBERGLASS)
YES
GROSS TONNAGE
NET TONNAGE
LENGTH
BREADTH
DEPTH
16 GRT
12 NRT
36.0
13.1
5.1
PLACE BUILT
UNKNOWN
OWNERS
OPERATIONAL ENDORSEMENTS
BEN ARAGONA
RECREATION
MANAGING OWNER
BEN ARAGONA
112 SCIENTIFIC LANE
JACKSONVILLE NC 28540
RESTRIC71ONS
NONE
ENTITLEMENTS
FORFEITED VESSEL - COASTWISE AND FISHERY. (FORFEITED BEFORE JULY 2, 2001)
R
REMARKS
NONE
APR 2 5 �022
0CM—iAHD CITY
ISSUE DATE
NOVEMBER 07, 2018
THIS CERTIFICATE EXPIRES'
2019
CwZeta.,,.Q °1
NOVEMBER 30,
J790
DIRECTOR, NATIONAL' VESSEL DOCUMENTATION CENTER
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This certificate is not valid for operation of the vessel until the vessel is marked with the name, official number, and hailing port as r
shown on the certificate. The original certificate must be kept aboard the vessel at all times when in operation and must be presented
upon the demand of federal, state or local officials for law enforcement purposes. Vessels with only a recreational endorsement may
not engage in commercial trade.
Documented vessels may be registered by states for tax and other purposes and may be required to display a state decal. This
certificate is valid for one year. Renewal is the responsibility of the owner. This certificate must be surrendered to the National Vessel
Documentation Center (NVDC), 792 T J Jackson Drive, Falling Waters, West Virginia 25419, upon a change in ownership, change in
state of incorporation, or a change in any other element shown on the certificate other than change of address. This certificate is
invalid for any vessel other than one documented solely for recreation when the vessel is placed under the command of a person who is
not a citizen of the U.S. The vessel and its equipment are liable to seizure and forfeiture to the U.S. government and the owner is
liable for a civil penalty of not more than $10,000.00 per violation. Each day of a continuing violation is a separate violation.
Any change in address of the managing owner must be reported promptly to the NVDC. You may contact us at (304) 271-2400.
Note: The certificate on the face of this document is not conclusive evidence of title in any proceeding where ownership is in
issue. Complete records are on file at the NVDC. The sale or transfer section below is provided for convenience only.
SALE OR TRANSFER OF VESSEL
100% OF THE VESSEL IDENTIFIED HEREIN IS SOLD (TRANSFERRED) BY THE OWNER(S) NAMED ON THE FACE OF THIS CERTIFICATE TO THE
FOLLOWING PERSON(S), ADDRESS MUST BE INCLUDED.
IF SOLD (TRANSFERRED) TO MORE THAN ONE PERSON, THE PURCHASER(S)/TRANSFEREE(S) ARE TENANTS IN COMMON, EACH OWNING AN
EQUAL UNDIVIDED INTEREST, UNLESS OTHERWISE INDICATED HEREIN: CHECK ONLY ONE OF THE FOLLOWING BLOCKS TO SHOW ANOTHER
FORM OF OWNERSHIP.
JOINT TENANCY WITH RIGHT OF SURVIVORSHIP TENANCY BY THE ENTIRETIES COMMUNITY PROPERTY
OTHER
SIGNATURE OF SELLER(S)/TRANSFEROR(S) OR PERSONS SIGNING ON BEHALF OF SELLER(S)/TRANSFEROR(S):
DATE SIGNED:
NAME(S) OF PERSON(S) SIGNING ABOVE, AND LEGAL CAPACITY IN WHICH SIGNED (E.G. OWNER, AGENT, TRUSTEE, EXECUTOR)
ACKNOWLEDGMENT (TO BE COMPLETED BY NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED BY A LAW OR A STATE OR
THE UNITED STATES TO TAKE OATHS.)
STATE:
ON THE PERSON(S) NAMED
(DATE) COUNTY: R E C E I V �' D
ABOVE ACKNOWLEDGED EXECUTION OF THE FOREGOING INSTRUMENT APR 2 5 ?0l'
IN THEIR STATED CAPACITY(IES) FOR THE PURPOSES THEREIN CONTAINED.
DCM-MHD CITY
NOTARY PUBLIC
MY COMMISSION EXPIRES:
PRIVACY ACT STATEMENT
IN ACCORDANCE WITH 5 USC 552(A). THE FOLLOWING INFORMATION IS PROVIDED TO YOU WHEN SUPPLYING PERSONAL INFORMATION TO THE U.S. COAST GUARD:
1. AUTHORITY. SOLICITATION OF THIS INFORMATION IS AUTHORIZED BY 46 USC CHAPTER 313 AND 46 CFR, PART 67.
2. THE PRINCIPAL PURPOSES FOR WHICH THIS INSTRUMENT IS TO BE USED ARE:
(A) TO PROVIDE A RECORD, AVAILABLE FOR PUBLIC INSPECTION AND COPYING, OF THE SALE OR OTHER CHANGE 1N OWNERSHIP OF A VESSEL WHICH IS
DOCUMENTED, WILL BE DOCUMENTED, OR HAS BEEN DOCUMENTED PURSUANT TO 46 USC, CHAPTER 121.
(B) RETENTION FOR EXAMINATION BY GOVERNMENTAL AUTHORITIES AND MEMBERS OF THE GENERAL PUBLIC.
3. THE ROUTINE USE WHICH MAY BE MADE OF THIS INFORMATION INCLUDES DEVELOPMENT OF STATISTICAL DATA CONCERNING DOCUMENTED VESSELS.
4. DISCLOSURE OF THE INFORMATION REQUESTED ON THIS FORM IS VOLUNTARY. HOWEVER, FAILURE TO PROVIDE THE INFORMATION COULD PRECLUDE
FILING OF A BILL OF SALE AND DOCUMENTATION OF THE VESSEL NAMED HEREIN PURSUANT TO 46 USC CHAPTER 121. MOREOVER, BILLS OF SALE WHICH
ARE NOT FILED ARE NOT DEEMED TO BE VALID AGAINST ANY PERSON HAVING ACTUAL KNOWLEDGE OF THE SALE. (46 USC 31321 (A)).
AN AGENCY MAY NOT CONDUCT OR SPONSOR, AND A PERSON IS NOT REQUIRED TO RESPOND TO A COLLECTION OF INFORMATION UNLESS IT DISPLAYS A
VALID OMB CONTROL NUMBER.
THE COAST GUARD. ESTIMATES THAT THE AVERAGE BURDEN FOR THIS FORM IS 20 MINUTES FOR COMPLETING AND 5 MINUTES FOR FILING. YOU MAY SUBMIT
ANY COMMENTS CONCERNING THE ACCURACY OF THIS BURDEN ESTIMATE OR ANY SUGGESTIONS FOR REDUCING THE BURDEN TO: U.S. COAST GUARD,
NATIONAL VESSEL DOCUMENTATION CENTER, 792 T J JACKSON DRIVE, FALLING WATERS, WEST VIRGINIA 25419 OR OFFICE OF MANAGEMENT AND BUDGET,
PAPERWORK REDUCTION PROJECT (1625-0027). WASHINGTON, DC 20503.
AR 545189222419
_ DHS, USCG, CG-1270 (REV Obi=04) bMB
a UNITED STATES OF, AMERICA
..b_. _ :
DEPARTMENT, OF HOMELAND SECURITY
`a UNITED STATES`.COAST GUARD
NATIONAL VESSEL DOCUMENTATION CENTER
1625-0027 C
CERTIFICATE OFDOCUMENTATION
VESSEL NAME
OFFICIAL NUMBER
IMO OR OTHER NUMBER
YEAR COMPLETED
STRAY HATT
682408
HATCR834K485
1 1984
HAILING PORT
HULL MATERIAL
MECHANICAL PROPULSION
JACKSONVILLE, NC
FRP FIBERGLASS
YES
GROSS TONNAGE
NET TONNAGE
LENGTH
BREADTH
DEPTH
37 GIRT
27 NRT
1 43.1
14.1
8.2
PLACE BUILT
HIGH POINT, NC
OWNERS
OPERATIONAL ENDORSEMENTS
BEN S ARAGONA
RECREATION
MANAGING OWNER
BEN S ARAGONA
112 SCIENTIFIC LANE
JACKSONVILLE, NC 28540
RESTRICTIONS
NONE
ENTITLEMENTS
NONE
REMARKS
APR 2 5 2-0
NONE
ISSUE DATE
AUGUST 15, 2007
�,zT's co ,
THIS CERTIFICATE EXPIRES
P5R.1TU5 �/�
AUGUST 31, 2008
DIRECTOR, NATIONAL VESSEL. DOCUMENTATION CENTER
170
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This certificate is not valid for operation of the vessel until the vessel is marked with the name, official number, and hailing port as
shown on the certificate. The original certificate must be kept aboard the vessel at all times when in operation and must be presented
upon the demand of federal, state or local officials for law enforcement purposes. Vessels with only a recreational endorsement may
not engage in commercial trade.
Documented vessels may be registered by states for tax and other purposes and may be required to display a state decal. This
certificate is valid for one year. Renewal is the responsibility of the owner. This certificate must be surrendered to the National Vessel
Documentation Center (NVDC) upon a change in ownership, change in state of incorporation, or a change in any other element shown
on the certificate other than change of address. 'Phis certificate is invalid for any vessel other than one documented solely for recreation
when the vessel is placed under the command of a person who is not a citizen of the U.S. The vessel and its equipment are liable to
seizure and forfeiture to the U.S. government and the owner is liable for a civil penalty of not more than $10,000.00 per violation. Each
day of a continuing violation is a separate violation.
Any change in address of the managing owner must be reported promptly to the NVDC. You may contact us at (304) 271-2400.
Note: The certificate on the face of this document is not conclusive evidence of title in any proceeding where ownership is in
issue. Complete records are on file at the NVDC. The sale or transfer section below is provided for convenience only.
SALE OR TRANSFER OF VESSEL,
100% OF THE VESSEL IDENTIFIED HEREIN IS SOLD (TRANSFERRED) BY THE OWNER(S) NAMED ON THE FACE OF THIS CERTIFICATE TO THE
FOLLOWING PERSON(S). ADDRESS MUST BE INCLUDED.
IF SOLD (TRANSFERRED) TO MORE THAN ONE PERSON, THE PURCHASER(S)/TRANSFF,REE(S) ARE TENANTS IN COMMON, EACH OWNING AN
EQUAL UNDIVIDED INTEREST, UNLESS OTHERWISE INDICATED HEREIN: CHECK ONLY ONE OF THE FOLLOWING BLOCKS TO SHOW ANOTHER
FORM OF OWNERSHIP.
ElJOINT TENANCY WITH RIGHT OF SURVIVORSHIP TENANCY BY THE. ENTIRETIES F] COMMUNITY PROPERTY
OTHER
SIGNATURE OF SELLER(S)/TRANSFEROR(S) OR PERSONS SIGNING ON BEHALF OF SELLER(S)/TRANSFEROR(S):
DATE SIGNED:
NAME(S) OF PERSON(S) SIGNING ABOVE, AND LEGAL CAPACITY IN WHICH SIGNED (E.G. OWNER, AGENT, TRUSTEE, EXECUTOR)
ACKNOWLEDGMENT (TO BE COMPLETED BY NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED BY A LAW OF A STATE OR
THE UNITED STATES TO TAKE OATHS.)
STATE: RECTEDVED
ON - THE PERSON(S) NAMED
(DATE) COUNTY:
APR 25 2022
ABOVE ACKNOWLEDGED EXECUTION OF THE FOREGOING INSTRUMENT
IN THEIR STATED CAPACITY(IES) FOR THE PURPOSES THEREIN CONTAINED. p
GM-MHD rUITY
NOTARY PUBLIC
MY COMMISSION EXPIRES:
PRIVACY ACT STATEMENT
IN ACCORDANCE WITH 5 USC 552(A). THE FOLLOWING INFORMATION IS PROVIDED TO YOU WHEN SUPPLYING PERSONAL INFORMATION TO THE U.S. COAST GUARD:
I . AUTHORITY. SOLICITATION OF THIS INFORMATION IS AUTHORIZED BY 46 USC CHAPTER 313 AND 46 CFR, PART 67.
2. THE PRINCIPAL PURPOSES FOR WHICH THIS INSTRUMENT IS TO BE USED ARE:
(A) TO PROVIDE A RECORD, AVAILABLE FOR PUBLIC INSPECTION AND COPYING; OF THE SALE OR OTHER CHANGE IN OWNERSHIP OF A VESSEL WHICH IS
DOCUMENTED, WILL BE DOCUMENTED, OR HAS BEEN DOCUMENTED PURSUANT TO 46 USC, CHAPTER 121.
(B) RETENTION FOR EXAMINATION BY GOVERNMENTAL. AUTHORITIES AND MEMBERS OF THE GENERAL PUBLIC.
3. THE ROUTINE USE WHICH MAY BE MADE OF THIS INFORMATION INCLUDES DEVELOPMENT OF STATISTICAL DATA CONCERNING DOCUMENTED VESSELS.
'I. DISCLOSURE OF THE INFORMATION REQUESTED ON THIS FORM IS VOLUNTARY. HOWEVER, FAILURE TO PROVIDE THE INFORMATION COULD PRECLUDE
FILING OF A BILL OF SALE AND DOCUMENTATION OF THE VESSEL NAMED HEREIN PURSUANT TO 46 USC CHAPTER 121. MOREOVER, BILLS OF SALE WHICH
ARE NOT FILED ARE NOT DEEMED TO BE VALID AGAINST ANY PERSON HAVING ACTUAL KNOWLEDGE OF THE SALE. (46 USC 31321 (A)).
AN AGENCY MAY NOT CONDUCT OR SPONSOR, AND A PERSON IS NOT REQUIRED TO RESPOND TO A COLLECTION OF INFORMATION UNLESS IT DISPLAYS A
VALID OMB CONTROL NUMBER..
THE COAST GUARD ESTIMATES THAT THE AVERAGE. BURDEN FOR THIS FORM IS 20 MINUTES FOR COMPLETING AND 5 MINUTES FOR FILING. YOU MAY SUBMIT
ANY COMMENTS CONCERNING THE ACCURACY OF THIS BURDEN ESTIMATE OR ANY SUGGESTIONS FOR REDUCING THE BURDEN TO: U.S. COAST GUARD,
NATIONAL VESSEL DOCUMENTATION CENTER, 792 T J JACKSON DRIVE, FALLING WATERS, WEST VIRGINIA 25419 OR OFFICE OF MANAGEMENT AND BUDGET,
PAPERWORK REDUC'rION PROJECT (1625-0027), WASHINGTON, DC 20503.
AH261695522419
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: BEN ARAGONA, SR.
Address of Property:
LOT 1, NEW RIVER PLACE, ON 201 LEONARD STREET
Mailing Address of Owner: 112 SCIENTIFIC LANE, JACKSONVILLE, NC 28540
Owner's email: cace@bizec.rr.com
Agent's Name: Timothy M. Stewart, P.E.
Agent's Email: office@tidewaterenc.com
Owner's Phone#: (910) 330-2237
Agent Phone#: (910) 455-2414
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 y"
mailed to 400 Commerce Ave., Morehead City, NC 28557. DCM representatives can also be contacted
at (252) 868-2608. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
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 someiaii of the 16 setback
•E
I do not wish to waive the 15' setbac
Signature of Adjacent Riparian Property Owner
rement (initial the blapk)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: DOUGLAS HEMBY
Mailing Address of ARPO: 180 LEONARD STREET, JACKSONVILLE, NC 28540
ARPO's email: ;' 7__ ARPO's Phone#:
Date: *waiver is valid for up to one year from ARPO's Signature
RECEIV ID
APR 28 2022
Revised July 2021
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ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
BRAXTON DAVIS
Director
August 22, 2022
Mr. C.D. Hemby
208 Leonard St.
Jacksonville, NC 28540
Dear Mr. Hemby:
1Nc SfArt _q
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NORTH CAROLINA
Environmental Quality
This letter is in response to your objections on the adjacent riparian property owners statement
dated August 6, 2022 regarding your concerns about the proposal by Mr. Ben Argona Sr. to
install a pier, platform and two slips located within the New River at 201 Leonard Street in
Jacksonville, Carteret County. The proposed project has been determined to comply with the
Rules of the Coastal Resources Commission (71-1. 1200), and as such, a permit has been issued to
authorize the development. I have enclosed a copy of the permit, as well as the relevant statutes.
If you wish to contest our decision to issue this permit, you may file a request for a Third
Party Hearing. The request for a hearing will be considered by the Chairman of the Coastal
Resources Commission. The hearing request must be filed with the Director, Division of
Coastal Management, in writing and must be received within twenty (20) days after the
disputed permit decision is made. I have enclosed the applicable forms and instructions
that must be filed prior to that deadline. Please contact me at (252) 515-5417, if you have
any questions, or if I can provide any additional information.
Sinicerely
Heather Styron
District Manager
D,. E
NORTH CAROLINA
Department of Environmental Dwli`ry�
North Carolina Department of Environmental Quality I Division of Coastal Management
Morehead City Office 1 400 Commerce Avenue 1 Morehead City, North Carolina 28557
252.515.5400
CAMA THIRD PARTY DCM FORM 5
HEARING REQUEST FORM DCM FILE No:
PETITIONER'S NAME
COUNTY WHERE THE DEVELOPMENT IS PROPOSED
PLEASE TAKE NOTE that the undersigned, a person affected by the decision of (check one):
a Local Permit Officer acting on a CAMA Minor Development Permit application; or
the Division of Coastal Management acting on a CAMA Permit application
hereby requests permission from the Coastal Resources Commission (CRC) to file an appeal pursuant
to N.C.G.S. § 113A-121.1(b) and 15A N.C.A.C. 07J .0301. (Please attach a copy of the permit. ff you
cannot obtain a copy of the permit, please provide the name of the permittee, the project location, and
the permit number.) Requests are reviewed and determined by the chairman of the CRC to determine
whether a hearing should be granted. 15A N.C.A.C. 07J .0301(b). Approval of a Third Party Hearing
Request allows a petitioner to file a contested case petition with the Office of Administrative Hearings
within twenty (20) days of receipt of the CRC's Order. N.C.G.S. § 113A-121.1(b). Denial of a Third
Party Hearing Request is a final agency decision which may be appealed to Superior Court under
N.C.G.S. § 113A-121.1(b) and Chapter 15013, Article 4.
For this application to be complete, the Petitioner must address each of the three factors listed below.
The CRC's chairman's decision to grant a hearing will be based on whether the Petitioner:
(1) Has alleged that the decision is contrary to a statute or rule [N.C.G.S. § I I3A-121.1(b)(1)];
(Please cite the statute or regulation allegedly violated by the permit decision.)
(2) Is directly affected by the decision [N.C.G.S. § I I3A-121.1(b)(2)]; and
(Please describe how you are directly affected by the permit decision. Persons directly
affected by a decision often include, but are not limited to, owners of real property in the
vicinity of the proposed development who can show that it is likely to have a significant
adverse effect on the value and enjoyment of their property, or persons who can
demonstrate a history of substantial use of public resources in the area directly affected
by the development.)
(3) Has alleged facts or made legal arguments that demonstrate that the request for the
hearing is not frivolous [N.C.G.S. § I I3A-121.1(b)(3)]. (Summarize the evidence and
arguments you would present at a hearing in support of your appeal explaining why the permit
was improperly issued.)
Please answer these questions on a separate piece of paper and attach it to this form.
The Commission notes that there are some opinions of the State Bar which indicate that non -attorneys may not
represent others at quasi-judicial proceedings such as this Third Party Hearing Request before the Commission.
These opinions note that the practice of non -lawyer professionals, such as engineers, surveyors or contractors,
representing others in quasi-judicial proceedings through written argument may be considered the practice of
law. Before you proceed with this hearing request, you may wish to seek the advice of counsel before having a
non -lawyer represent your interests through preparation of this Petition.
DELIVERY OF THIS HEARING REQUEST
This request must be received by the Division of Coastal Management (DCM) within twenty (20) days
of the date of the disputed permit decision. N.C.G.S. § I I3A-121.1(b). Failure to do so constitutes
waiver of the right to request a hearing. A copy of this request must also be sent to the Attorney
General's Office, Environmental Division. 15A N.C.A.C. 07J .0301(b).
Contact Information for DCM:
By mail, express mail or hand delivery:
Director
Division of Coastal Management
400 Commerce Avenue
Morehead City, NC 28557
By Fax:
(252) 247-3330
By Email:
Check DCM website for the email
address of the current DCM Director
www.nccoastalmanagement.net
Contact Information for Attorney General's Office:
By U.S. mail:
Environmental Division
9001 Mail Service Center
Raleigh, NC 27699-9001
By express mail:
Environmental Division
114 W. Edenton Street
Raleigh, NC 27603
By Fax:
(919) 716-6767
Based on the attached responses to the above factors, the undersigned hereby requests a third party
hearing.
Signature of Petitioner or Attorney
Printed Name of Petitioner or Attorney
Mailing Address
City State Zip
Updated: February 2011
Date
Email address of Petitioner or Attorney
Telephone number of Petitioner or Attorney
Fax number of Petitioner or Attorney
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