86712A

o�0`°""41&❑CAMA ❑ DREDGE & FILL N° 86712 "A,B C
1 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:
I SA NCAC 4 t4 k t v i I` ❑ Rules attached. ❑ General Permit Rules available at the following link: [e-mail]/CAMAruIes;
Applicant Name
Address 5. r' w ,,� C I
City r State N Q_ ZIP 7)1 `" 3 `s
Phone # („ ) V , - L4 C R 1
Email k 4t + i-� rLc. t 7e, o
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s) S< N I C.
Subdivision
City ZIP of �r:l
Affected ❑ CW ❑ EW ❑ PTA 0 ES 0 PTS Adj. Wtr. Body �i 1 ? p 1)p;_. c � I �; (nat/TarVunk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
Shoreline Length "SAO
f;6�
Access Length
Pier (dock) length
X H
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Total Platform area
Groin length/#
(Bulkhead/ Riprap length
1-46
Avg distance offshore
Breakwater/Sill
Max distance/ length
Basin, channel
\
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other j'Ict� ...
L...-r�
t�. L�
SAV observed:
yes no
Moratorium: /7i%a
yes no
Site Photos:
ctsg?no
Riparian Waiver Attached:
. ye3_> no ,
A building permit/zoning permit may be required by:
Permit Conditions
. . , � � C It, 0,
(Scale: N T S )
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
1 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
k
Signature "Please read compliance statement on back of permit" Signature
Application Feels) Check #/Money Order Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: /:imy ' � k le `,r Mailing Address: fO 5" S (ZDD5F&)s�r, t'T_
N,
Phone Number: 7.57 - (o - 469
Email Address:-f-"JM�k(ar® &'T ZzFgy C o r►'-
I certify that I have authorized SEFF I
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: C> I `c/
��6-( /4",/1-C/ 4 /'� /K
at my property located at _109 N. G. CT.
in Cokgy do '- County.
I 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:
Signature
Print or Tye Name
Dweey4
Title
/I %d / 7 0/
Date
This certification is valid through I I

d (V 6WX4X�etw V &c, 7
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Owner:
Xe
r—
Address of Property: Za EE /y jCC2ZeZ L%!!1 G l re) t (X XI-e-
(Lot or Street ##.. Street or Road, Cityl County)
Agent's Name #: / h Mailing Address: D. �'_�!�L 4�►'L
Agent's phone
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for thi permit has described to me as shown on the attached drawing the development
they are pr sing. 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.
If 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 401 S.
Griffin St., Ste 300, Elizabeth City, NC, 27909. DCM representatives can also be contacted at (252) 264-
3901. 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, 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. (If you wish wive 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.
(Topert Owner I n ^rm 2
��// i//
S[tinallcr`lI
Tvo' Om-�Wia�
Print or Type Name
AT S CT.
Mailing Address
GOIODV N. L A-29367
City/State ip
757 64,1-46 9t -f-c kwilQ 007b a & xm
Telephone Number / Email A dress
l �UIc'
`Valid for one calendar year after signature"
acent
S'igncuurc'�
Print or Type Name
Mailing Address
Information)
City/StatelZip
a,��q - (o Z7 -
Telephone Number / 077ail Address
Revised Jan. 2017

P-tpvk C-�'- 0y Zh //� CG(Y A /)OC K"-
A
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Owner: %. r1Vl. �,.���� l e,
,, 1 C �
Address of Property: - --Zo� /V r �csc� d� 1� st'� C �✓ (Lot or Street #, Street or Road, City & C nty) ?
Agent's Name Mailing Address �t) �G �� GcA—
Agent's phone #: acS^a; �7� 6- 15'
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.
V`'� t have no objections to this proposal. �_,__ I have objections to this proposal.
If 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 401 S.
Griffin St., Ste 300, Elizabeth City, NC, 27909. DCM representatives can also be contacted at (252) 264-
3901. 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, 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. (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 Owner Info m tion)
1;l:!/1Cl 111'N
Print or T pe Name
/D.;- S. C,rrao L,0R& G �T
Mailing Address
aV At G A2W
City/Stat /Zip
(Adjacent Property Owner Information)
.�1 �rr7(1l1IPC' x
Print or Type Name
eq�F'0
Mailing Address
City/Sta e2ip
Telephone Number / Email Address �— Telephone Number/Email Address
a
l ue *Va d for one calendar ear of er si nature* 1 r`r�ri J
*Valid for one calendar rear aftter sr�nature,�>�i:ti7%

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