86997A_Grgurich, Jacob & Rosa_20230111

1+OCJCAMA ❑ DREDGE & FILL N° 86997 v -A )B C D
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:
I SA NCAC 4U Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.Yov/CAMArules
Applicant Name
Address
City State ZIP
Phone # ( ) 0
Email
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City ZIP
Affected ❑ CW E:EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
(Scale: w=S )
Shoreline Length
Access Length _
Pier (dock) length
Fixed Platform(s)
Floating Platform
Finger pier(s)
Total Platform are
Groin length/# _
Bulkhead/ Riprap
Avg distance offsl
Breakwater/Sill _
Max distance/ ler
Basin, channel _
Cubic yards _
Boat ramp
Boathouse/ Boatl
Beach Bulldozing
Other
SAV observed:
Moratorium: n
Site Photos:
Riparian Waiver A
A building permit/zoning permit may be required by: Cu t r + tiC C� .
Permit Conditions +
❑ 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.
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit" Signature
(Please Initial)
Application Feels) Check #/Money Order Issuing Date Expiration Date

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: ��Ca49 (0y�.iC h
Address of Property: /�% .r—�� 74�2 A,,o <-)it ST p
Mailing Address of Owner: ��%7 .��/yy !l�>J s%
Owner's email: 3-e C Coow ner's Phone#:
Agent's Name: ��� Agent Phone#: - -- 4 36 Z
Agent's Email:
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
I DO NOT have objections to this proposal. I DO have objections to this proposal
Tf 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 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. 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 som &
the 15' setba
ure of Adjacent Riparian Propert wrier
-OR-
Sign
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: 3�2M 0< C ll
Mailing Address of ARPO: � Ba- n4 / P A L cc )� nrn� --/rl oyo� �,-2
ARPO's email: ARPO's Phone#:_t']�_�� n��0
Date: Z0 ti(?CaD� r�"`waiver is valid for up to one year from ARPO's Signature"
Revised May 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:-ZnLCd[3 s 1 0 I G
Address of Property: % S%
Mailing Address of Owner /6 7 2�;,ln PQ 57 1V6)�(4QC.k A, rR ;1? a
Owner's email: ��Cj tki� � � C�n1 Owner's Phone# IR I R ` -1 oo
Agent's Name: Agent Phone#: 33-3
?�. C t�vd �� `tJvl S �
Agent's Email:
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 tnis letter
D_y 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 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. 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&f the 15' setback
Signature djacent Riparian Property Owner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: , J (1 fin Q S O
Mailing Address of ARPO: __Z n g F % n, a ���� ul `7 T n L Ifs CSC % /Uc- c�79
ARPO's email: ARPO's Phone#: a 53 - a-,3 2 - 39,E 5
Date: % L) Q&_Djo IUwaiver is valid for up to one year from ARPO's Signature'
Revised May 2021

„�A,o`p"k ❑CAMA ❑ DREDGE & FILL L N9 86750 A B C
Previous permit
GENERAL PERMIT
� Date previous permit issued
e'.i'- \\ h, o t 1,.'a.
❑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.ncgov/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 1-1 EW ❑ PTA
ES ❑ PTS Adj. Wtr. Body (nat(manJunk)
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)
i
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 3
5
Boathouse/ Boatlift f
z
Beach Bulldozing s,
Other
SAV observed: yes no
Moratorium: n/a yes no
Site Photos: yes no
Riparian Waiver Attached: yes no
A building permit/zoning permit maybe required by: .
Permit Conditions
(Scale: i , )
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** Sigilatur�e
Application Feels) Check #/Money Order Issuing Date Expiration Date