Holland, Jeffrey 88859C

NO 59 A B C D
\p�pECOAstq�o� ❑CAMA ❑ DREDGE & FILL
y 9= 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
s
Applicant Name.,:.
Address
b
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
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
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
SAV observed: yes no
Moratorium: n/a yes no
Site Photos: yes no
Riparian Waiver Attached: yes no
A building permit/zoning permit may be rE
Permit Conditions
ZIP
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nk)
r
(Scale: )
U TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
Agent or Applicant PRINTED Name
Signature "Please read compliance statement on back of permit"
Permit Officer's PRINTED Name
Signature r
Application Fee(s)
Check #/Money Order Issuing Date
Expiration Date

01`°AS'V c❑CAMA ❑ DREDGE & FILL NO* 88859 A B C D
I 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
Phone # ( )
Email
State
ZIP
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body
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 len€
Avg distance offshore
Breakwater/Sill
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift _
Beach Bulldozing
Other
SAV observed:
Moratorium: n/a
Site Photos:
Riparian Waiver Attac
A building permit/zoning permit may be required by:
Permit Conditions
ZIP
nat/man/unk)
(Scale: )
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (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

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner:
Address of Property: ,
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Mailing Address of Owner: )� � r v � e- d- � . �
Owner's email ��� r�'� �� �'��°v✓1
Agent's Name: ,) Y` C' ►� r ��
Agent's Email:
Owner's Phone#: � �i 7 a LI
Agent Phone#:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed 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.
\L I DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 400 Commerce Ave., Morehead City, NC 28557. DCM representatives can also be
contacted at [phone]. No response is considered the same as no objection if you have
been notified by Certified Mail.
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sicn
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
-OR-
V�-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner: I Y \
�I
Typed/Printed name of ARPO:
Mailing Address of ARPO: ` lQ 1 F �I `'" 'y �- c S S�
ARPO's email: ARPO's Phone#:
�-:
Date: "waiver is valid for up to one year from ARPO's Signature"

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CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: ✓� j� V
P Y
Address of Property: 1 �� 1 ���1�i� i'�/ 4-7r C� �� , l-; ��� tJl�r�, �' Z-
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(Lot or Street #, Street or Road, City & County)
Agent's Name #: yt I/•
Agent's phone #: S- 1 01- 7 3 2-1
Mailing Address: ,162 %��� e"D�
fC,
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 ar proposing. A description or drawing, with dimensions, must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
/f you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Correspondence should be mailed to 400
Commerce Ave., Morehead City, NC, 28557. DCM representatives can also be contacted at [phone].
No response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that 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. (if 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 P,wner InfprmAtio,
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Print or Type Nalne
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Mailing Address /
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City/State/Zip
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Telephone Number
(Adjacent Property caner Information)
Signature
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Print or Type Name
lvw, V\ L -r-
Mailing Address
ltil - l�
City/State/Zip
Telephone Number

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