86995A_Forsdick, Randall_20221221

`OW4, ❑CAMA ❑ DREDGE & FILL �' N° 86995 A, B C D
V G E N E RAL PERMIT Previous permit
Date previous permit issued /
El New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue V
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 ❑ Rules attached. ❑ General Permit Rules available at the following link: www.dgq.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 (nat/man/unk)
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 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
Signature `*Please read compliance statement on back of permit"
Permit Officer's PRINTED Name
Signature
Application Fee(s)
Check #/Money Order Issuing Date
Expiration Date

REC E I IJIS D
NO V 2 2 2022
DCM-EC
AGENT AUTHCHWATM FOR CAM PERT APM"TM
Email Address:
i cm* that i nave authorized L
to act on my behalf, for the purpose of applying for and obiakng al{ LAMA perffft
ter„ for the ftWw*V woposed dev lowr a 11L)
at my property located at / 6
in P& County.
l furthermore cer* that 1 am authorised to gram and do in fact grant permission to
Dmwon of Coastal A6mVement staff, the Local PL-nW Officer and rhea agents to enter
our the atofeamboned tends in connecWn with eveluahng infomuftn related to this
Permit appffcaftn.
PhW or Type Marne

RECEIVED
NO V 2 2 2022
N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER OTIFICA IONIWAIVER FOR C M- E C
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:
Mailing Address of Owner. LAJ 2 - )v 0-NW
r a.nA I '
Owner's email: r i r � I i i� C�Yh Owner's Phone#:
Agent's Name: I I V) 1 `i 1a yi ne- Agent Phone#:15D - �� (10 3
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
riasrrinfinn or rfinwino- with dimensions- must be orovided 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 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 15from 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.)
�1 L.
I DO wish to waive some/all of the 15' setback
Signature Adj,acent Riparian Property O ner
-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:
Mailing Address of ARPO:
ARPO's email:
ARPO's Phone#:
Date: waiver is valid for up to one year from ARPO's Signature"

RECEIVED
NOV 2 2 2022
N.C. DIVISION OF COASTAL MANAGEMENT
DCM-EC
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: I tp o� LN'I V\o(-k,d C La -oe- I, P e, ci 1� .� , �lU C 2 - Y L/
Mailing Address of Owner. o� U��t VITd df' a-� e-11 C a -7
ra�,r�� -� � . I • r1
Owner's email: YJ� t'. � I .60m Owner's Phone#: 9 5 I ' 3-Zi- .5 a r7
Agent's Name: L Cl �� ri Y Agent Phone#:
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 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 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 Certirted 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
Signature of Adjacent 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:
Mailing Address of ARPO:
ARPO's email: ARPO's Phone#:
Date: *waiver is valid for up to one year from ARPO's Signature*

N�
FJ ov� N'an,Y
co w�
RECEIVED
Nov 2 2 zon
DCM-EC
cl 4 line -
I
fidJus-i,nwY
erof 0/1,
D t-./i l IL

� - i

12/1/2022, 11:33:13 AM
perquimans nc misc
perquimans_nc_lot
perquimans_nc_easement
Perquimans GIS It
perquimans__nc_dims Imagery 2020 0 Blue: Band_3
perquimans_nc_acres M Red: Band 1 Q Imagery2016
Green: Band--2
�-►h4ci
1:2,257
0 0.01 0.03 0.06 M
0 0.02 0.04 0.09 krn
State of North Carolina DOT, State of North Carolina DOT Esn, HERE, Gamin.
Goo 1 ec.hnoR8JIY7. Inc , USGS. EPA
Perqurmans CIS
f nr tax purposes only l,kd a legal nrx:ument or survey Prrqulmans nix Slate of W: assume any liability rnsultinq true use cal this map