89696A - Gaskins, John

�'Aco to ❑CAMA ❑ DREDGE & FILL Nv 89696 K A B C C
a GENERAL PERMIT Previous permit
� Date previous permit issued
M 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 � � ' ❑ Rules attached. 'A❑ General Permit Rules available at the following link: vvmvdeq.nc.gov/CAMArules
Applicant Name _
Address
City
Phone # ( )
Email
State 1 zip
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Win Body (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Mal. Wtr. Body
ORW: yes/no PNA: yes/no
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A building permit/zoning permit maybe required by:
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. (Please Initial)
Agent or Applicant PRINTED Name
Permit Officer's PRINTED Name
Signature *'Please read compliance statement on back of permit"
Application Feels) Check #/Money Order
Signature
Issuing Date
Expiration Date

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER
JoI:
Name of Property Owner:
Address of Property:
ECEI V EL
APR 12 113
nCM-EC
Mailing Address of Owner:
Owner's email: Owner's Phone#:
Agent's Name:
Agent's Email:
Agent Phone#:
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
descriptionordrawing, with dimensions, must be provided with this letter.
V 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 (Choose only onel
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 revetments1. (If you wish towaive jhe setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback }\�
9410
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Owner: `-1,4)3LIT A hJ, �� �o �Tu� _ U/�/r /•+�
Typed/Printed name of ARPO: �`y �L.�¢�il�'—�LJt q//`Lo© r�RT w—'
Mailing Address of ARPO: 1011.2 /04 /-rFNAl( !,J
ARPO's email: ARPO's Phone#:
Date: L/-lD ��� *waiver is valid for up to one year from ARPO's Signature*
Revised August 2022

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM���t ii d€ s 9
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY d*`[[ 1 V C 8..a!
(Top portion to be completed by owner or their agent)
Name of Property Owner
Address of Property:
Mailing Address of Owner:
Owner's email:
Agent's Name:
Agent's Email:
? Owner's Phone#: z337J;—�1
Agent Phone#:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
APR I Z ZUB
I herebycertify 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 Certified Mail.
WAIVER SECTION (Choose only one
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.) ^ - . (\ f
i DO wish to waive some/all of the 15' setback
of Adjacent Riparian Property
9•1ta
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO:JV^0A\ ov\ � 1hC�\ 4�l w.bQV-1 / NT-' Vt v-oSph
n ` 1
Mailing Address of ARPO: Yr G n b V— I ye—
ARPO's email:
ARPO's Phone#:
Date: T — 1 V —�3 *waiver is valid for up to one year from ARPO's Signature*
Revised August 2022

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