87569D-INMAN

�❑CAMA ❑ DREDGE & FILL N9 87569 A B C
-N, GENERAL P E R M I T I� I C� Previous permit ' 33
J
i t prev' us ermit issued
Q New ❑ Modification ❑ Complete Reissue ❑ Partial Reissu ld 1� L�'
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in ar of environmental concern pursuant to:
15A NCAC C " ❑ Rules attached. General Permit Rules available at the following link: www.dgq.nc.gov/CAMArules
Applicant Name t ` �•'� T'`� (. �� Authorized Agent
Address Project Location (County):
City VA' '^ State % )< ZIP Street Address/State Road/Lot #(s)
Phone # O 1 Ci >lUS
Email , . . i . r-
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: yet/no) PNA: yes/no
Type of Project/ Activity a
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJ
Agent or Applicant PRINTED Name
Signature,"Please read compliance statement on back of permit"
Application Feels) Check #/Money Order
(Scale: N S )
U See additional notes/conditions on back
AND REV!EWEp COMPLIANCE STATEMENT. (Please Initial)
Permit s-PRTNTERName
--
Signature ILI
Issuing— Expiration Date

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:
F] 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: [phone]
(Serves: Carteret, Craven — south of the Neuse River, Onslow
Counties)
Elizabeth City District
401 S. Griffin St. Ste. 300
Elizabeth City, NC 27909
252-264-3901
(Serves: Bertie, Camden, Chowan, Currituck, Dare, Gates, Hertford,
Pasquotank and Perquimans Counties)
Washington District
943 Washington Square Mall Washington, NC 27889
252-946-6481
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
910-796-7215
Fax: [phone]
(Serves: Brunswick, New Hanover and Pender Counties)
http://portal.ncdenr.org/web/cm/dcm-home Revised 6/01/2021

NCAMA 7 DREDGE & FILL SIP 87569
i Previous per—
11 GENERAL PERRll 9 Ti Date previous permit issued / 1*1
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New ❑Modification QConviete Reissue [ ]Partial Reissue
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( r 0 see note on "k rebwo" aner Barr rules
0 see addmanal rwres/cund tors on back
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N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion
to
be completed by owner or their agent)
Name of Property Owner: rT I �T PAC--(0
Address of Property: �7 , {C�% (J
%r�-�
.
Mailing Address of Owner: `Z OZ
�1 ✓Lv✓L4wt®0( C`ow
Ownersr'
email: Owner's Phone#: ( 1�,��
Agent's Name: /v Agent Phone#: / A -
Agent's Email: %i A
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.
t-�0 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.127 Cardinal Drive EXT, Wilmington, NC 28405. DCM representatives can also be contacted at
[phone]. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distance of 15' from my area of riparian access unless waived by me (this
does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign the
appropriate blank below.)
I DO wish to waive some/all of the 15' setback
-OR-
Signature of Adjacent Riparian Property Owner (ARPO)
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
h/.
Typed/Printed name of ARPO:
Mailing Address of ARPO: Zc' 7)j^
ARPO'semail:_�--�itlS�'rt'ARPO's hone#: k-f(j) to0to-k3c�3
a-,
Date: %d L 24' *waiver is valid for up to one year from ARPO's Signature*
Revised May 2021
Z�Fr*-0S

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion
to be completed by owner or their agent)
Name of Property Owner: �'C 1 �ax--L
Address of Property: �7 , r�. Q- — --
Mailing Address of Owner: Jam! rj�; I� �7r•ikCft�c _ `� �7�
Owner's email: O�--! ✓lv✓tqwt®��. {r Owner's Phone#:
Agent's Name: Agent Phone#: /J A —
Agent's Email: PA mot'
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 ha escnbed to me, as shown on the attached drawing,. the development they are proposing.
e. -A. ........ .......__ -- --- .. . ... -- . -
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 127 Cardinal Drive EXT, Wilmington, NC 28405. 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 wishtowaive the setback, you must sign the
appropriate blank below.) r� �:r� • q /'A LL�%�
1 DO wish to waive some/all of the 15' set
-OR-
S} ram'
Signature of Adjacen iparian Property Owner (ARPO)
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property
Typed/Printed name of ARPO:
Mailing Address of ARPO: eq/w
ARPO's email:
ARPO's Phone#:
Date: %O — .LJ'— % *waiver is valid for up to one year from ARPO's Signature* •'°�
Revised May 2021

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