87601D-ADCOCK

cAR4, ❑CAMA ❑ DREDGE & FILL N9 87601 A B C D
3
GENERAL PERMIT vasv Previous permit
J Date revi us permit issued
❑ New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue I a1
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission an a ea of environmental concern pursuant to:
15A NCAC ❑ Rules attached. 0 General Permit Rules available at a following link: www.dgq.nc.gov/CAMArules
Applicant Name Authorized Agent
Address Project Location (County):
City State ZIP Street Address/State Road/Lot #(s)
Phone # (_ )
Email Subdivision
City ZIP
Affected ❑ CW ❑ EW ❑PTA ❑ ES ❑ PTS Adj. Wtr. Body,,...-f,� -( na man/unk
( d )
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 lei
Avg distance offshor
Breakwater/Sill _
Max distance/ lengt
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing _
Other
SAV observed:
Moratorium: n/a
Site Photos:
Riparian Waiver Attz
A building permit/zoning permit may be required by:
Permit Conditions
(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

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 F-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

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Ck- Si-► CA k[e0eV,
Mailing Address: W 0 OUI �Loee-} bcicvr br .
AILL
Phone Number: I4P v i n q 19 331 Lo t %3 Z1 i c,4 33 Lo 3310OL 1
Email Address: go-hmLncA- 9-
I certify that I have authorized CoM
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: bu 1 �t,,� 1eart 1,� L.JCI i
e a 30 At &son (-biv,4 OJ, 5ur{ Citt4 , KJC
at my property located at IA3
in P (L County.
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I furthermore certify that I 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
\�eyi i'\ Ind co C,\(- 4 (rfi ) �deo �-
Print or Type Name
Owc) 2c'S
Title
Date
This certification is valid through I I
NC

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at
on
(Wai
The applicant has described to me, as shown below, .the development proposed at the above location.
J have no objection to this proposal. -
have objections to this proposal. 1 se VU ti one cpihcx)
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must.fill in description below or attach a site drawing)
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WAIVER SECTION
! understand that a crier, 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
J do not wish to waive the 15' setback reauirement. p l ecise- mcc L O*e co,,
(Property Owner Information) (Adjacent Property Owner Information)
0 �a
Signature Si e
eV
Print or Type Name /I / !< I
Print r Type Name
Mailing Addressld L� Ott' �tlrtir �('
NN(ling Address
City/State/Zip Y 1 l t
CKY(1Scat ip
I 3 3 to t $3n.. 33 `1- r-1
Telephone Number Telephone Number
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Date Date
Revised 611812012)

In
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SENDER:SEC
COMPLETE SECTIONON
DELIVERY
Complete items 1, 2, and 3: °"� '
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` A. Signature
■ Print your name and address on the reverse'..:
so that we can return the card to
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❑Agent
you.
■ Attach'this card to. the back -of the mailpiece,
or on the front if space permits.
B. Re ived y Pr! d Name )
Addressee
C. D to of Delivery
1. Article Addressed to:
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D. Is deliv address different from item 1? ❑ es
If YES,,enter delivery address below: ❑ No
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11 ❑ RegisteMail red Maill- ss®
9590 9402 5799 0084 425 Z 1,3
Certified Mail®
❑ Certified Mail Restricted Delivery
p Registered Mail Restricted
Delivery
❑
?. Article Number (Transfer from service lahe4
Collect on Delivery
❑ Collect orb Delivery Restricted Delivery
Return Receipt for
Merchandise
13 Signature ConfrmaUon-
7020 316 0 0001 5282 2 418 lail
if Restricted Delivery
❑ Signature Confirmation
Restricted Delivery
t` PS Form 3811, JUIy 2015 PSN 75-30-02-000-9053
•
Domestic Return Receipt

� T USP TRACKING # Flrst C ass; Magi
f 70 Postaiye & Fees 1='aid
J USPS
I f- Permit No.` G-10
9590 9402.5799 0034:42'52 13
United States •Sunder: Please Pont your name-0ddress, and ZIP+4® in rnis b xm
Postal Service
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USPS Tracking'
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Tracking Number: 70203160000152822418
Your item was delivered to an individual at the address at 3:19 pm on April 11, 2022 in
BURLINGTON, NC 27217.
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April 11, 2022 at 3:19 pm
BURLINGTON, NC 27217
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April 11, 2022, 3:19 pm
Delivered, Left with Individual
BURLINGTON, NC 27217
Your item was delivered to an individual at the address at 3:19 pm on April 11, 2022 in BURLINGTON, NC
27217,
April 11, 2022, 9:08 am
Out for Delivery
BURLINGTON, NC 27217

1 i �
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April 11, 2022, 8:57 am
Arrived at Post Office
BURLINGTON, NO 27215
April 10, 2022
In Transit to Next Facility
April 9, 2022, 3:34 am
Departed USPS Regional Facility
GREENSBORO NC DISTRIBUTION CENTER.
April 8, 2022, 11:08 am
Arrived at USPS Regional Facility
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April 8, 2022, 12:50 am
Arrived at USPS Regional Origin Facility
CHARLOTTE NO DISTRIBUTION CENTER
April 7, 2022, 4:41 pm
Departed Post Office
HOLLY RIDGE, NO 28445
April 7, 2022, 2:48 pm
USPS in possession of item
HOLLY RIDGE, NC 28445
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v

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:
Address of Property: of -S D /74Kl&SIUl1 /' iO 04-J. 6LAr Ci �q NC d 0 yyJr
Mailing Address of Owner: 14 OL -4WeG4'hr1'0r" J)r Ra leigh NG 97i9D9
Ks�dc�cu.8� 1 � yahoo. ems,,
Owner's email:eq;rcy►,coregp Id o Owner's Phone#: �eyiil 919337Co1�'3 L�J'ic�133�339�!
Agent's Name:_ �'CCM Agent Phone#:
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacent 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 127 Cardinal Drive Ext., Wilmington, NC 28405-3845. 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' se a k 6
-OR-
� - • ��� ; �/,^
Signature of Adjacent Riparian Property OwrYer
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner7]61��
Typed/Printed name of ARPO: /3 ass
Mailing Address of ARPO: ftx S7 7
Cn,oss too �38 a� gr�i� Ca—
ARPO's email: K ARPO's Phone#: `il p 0 )[
Date: -)'a 62, 2 0 22- *waiver is valid for up to one year from ARPO's Signature* k
V ('�� Ck �j �..� Revised July 2021
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