89603A-Scott

&OCAMA 0 DREDGE & FILL NO 89603 A B C D
fA GENERAL PERMIT Previous permit
Date previous permit issued
E]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. ❑ General Permit Rules available at the following link: www.decinc gov/CAyIArules
Applicant Name _
Address
City
Phone # ( )
Email
State
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s) _-
Subdivision
City
P
Affected ❑ CW ❑ EW ❑ PTA ❑ ES R. 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:
Shoreline Length
Access Length
Pier (dock) length I
i
!
I
T--
I,
, T
_...._-�
•_
Fixed Platform(s)it
-
-
-L_
--
,--
---{
-`--
-
_
I
Floating Platform(s)
I
j
I
j
Finger pier(s)
Total Platform area
r'
I
Groin length/#
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/Sill
Max distance/ length
Basin, channel
Cubicyards
Boat ramp
Boathouse/ Boatiift
Beach Bulldozing
Other
_
i'
�..
-I-
;tti
t
I
-
1
-{--
1
1
t
1
1
-
-'
\
-
j
14
-�
1
i
SAV observed: yes no
Moratorium: . n/a yes no
Site Photos: no es
Riparian Waiver Attached: yes no
,-J—
�.--:,__
f
s"
__�
A building permit/zoning permit maybe required by:
❑ 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
Agent or Applicant PRINTED Name
Signature **Please read compliance statement on back of permit**
Application Fee(s) Check Jt/Money Order
Permit Officer's PRINTED Name
Signature
Issuing Date'
Expiration Date

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit:
Mailing address: 16600
Telephone Number:
0-*"�, VA 23 00Z
(go �93q Z3b3
I certify that I have authorized "`� �"�— (agenticontractor),
to act on my behalf, for the purpose of applying and obtaining all
CAMA permits
necessary for the proposed development of / ��" OtvYrt 4 en
at my property located at
This certification is valid through IZ f 1-2-- l (date).
(Property Owner Information)
' J rj
-Z4
Signature
Print or Type Name
Title, co. owner or trustee for property
--I A10/3
Date
804-Dq-z363
Telephone Number
0,•
Email Address
FECEIVIED
FLB 2, 0 2023

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER 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 Properly:
Mailing Address of Owner: N WOO 0 LOSMIk bAt LA, (tAtkiA t A
Owners email: C50A I hW-MOA( EO Owner's Phone#: _20L1 - 83ti• ?-U5
Agent's Name: Pao 0 C(WIX61115P GtM 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 adjacentto 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'fl DO NOT have objections to this proposal. 1 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 o/ this notice. Correspondence should be
mailed to 90 Washington Square Mall, Washington, NC 27889. DCM representatives can also be
contacted at [phone]. No response is considered the same as no objection N you have been
notified by Certified Mall.
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.)
100 wish to waive somelatl of the 15' setback
G
Signature o/ A97acent Riparian Property Owner a----
-OR- if t..J
I do not wish to waive the 15' setback requirement (Initial the blank)
I-tH g p 2023
Signature of Adjacent Riparian Property Owner:
TypedtPrintedname ofARPO: aA
Mailing Address of ARPO: D D jU ,f
ARPO's emai dtr[Ai��o.Wsti/Cd.�r ARPO's Phone#: 757-d�.Si-?g: �
Date: D 'waiver is valid for up to one year from ARPO's Signature'
Revised Juts 102 r

'JILA
Ln.
"Mtn :0 -4
lips, fyj tins
nev ... :WNW 4 Mob= tc ant you his, Awww sj"h,k'
pzt CEIVED
ttfl 2 0 2023
) 'N

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to C\ OL COLA,s
2 Name of Property Owner
property located at 421A Bawx-c�of 4 Dr.Wthd50(, N �
(Address_ Lot, Block Road, at-.j
on R\btthane SpLu(� —,in_ W �N� S o1 , [ , N.C.
(Waterbody) (Clty/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must till in description below or attach a site drawing)
FEB 2 ) 2023
DCM_�('
WAIVER SECTION
I understand that a pier, 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.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
Signature
C\Gk SLo'tt
Print or Type Name
10(gft Lbaisi Pitt Ln
Mailing Address
c ►I .gP. 23002
City/Statemp
aO4 - S61-2.3b3
Telephone Number
Signature
Pr(f.4il or r
Mailin Add/ragss
r � N/dl'
City/Sta�lLd % f(�_
Telephone Number
2<Z- 4901,2rrt'-2-
Date
(Revised 611812012)

DCMRFC

I�
&
$
7
�
�
Q
�
\
It
Co-
\
co
q
cu
c
7 )