86892A - Evans

°"°"'" ❑CAMA ❑ DREDGE & FILL NU 868y2 HIV p, e C D
Previous permit
.= GENERAL 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.deq.nc.goy/CAMArules
Applicant Name
Address
City
Phone # ( )
Email
State ZIP
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s) -
Subdivision
City" ZIP
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PITS Adj. Wtr. Body (nat/man/unk)
AEC(s): ❑ IDEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
(Scale:; )
Shoreline Leneth
Access Length
i
Pier (dock) length
1
Fixed Platform(s)
C
)
_ _.t.
_
I
P
Floating Platform(s)
Finger pier(s)��.
Total Platform area
I
+..
_
Groin length/#
- i
-
-
Bulkhead/ Riprap length
----
.r---
—
Avg distance offshore(-
Breakwater/Sill
Max distance/ length
�-
Basin, channel --
-r
Cubic yards-_--
I
•_
Boat ramp
Boathouse/ Boatlift
Beach BulldozingOther
r
c
SAV observed: yes no
Moratorium: n/a yes no
1�
Site Photos: - yes. no i
-,-
�-
-r-
Riparian Waiver Attached: yes no
A building permit/zoning permit may be 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
Signature "Please read compliance statement on back of permit**
Permit Officer's PRINTED Name
Signature
4/21 /Z3 `-/z(/Z.3
Issuing Date Expiration Date
Application Feels) Check #/Money Order

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: _
Mailing Address of Owner:
Owner's email: E% elet.)
Agent's Name:
Agent's Email:
0
2
Owner's Phone#: i2.5 ,2-' V.;7 - CiE>s
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 forthis
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.)
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 Owne
Mailing Address ofARPO: 322 6244 Hk/r Laxlt A P1, `m12., 4/� 723,2--
ARPO's email: d/ s ARPO's Phone#: _;V 5 ii J . � OL
Date: 3�r 3 'waiver is valid for up to one year from ARPO's Signature'
Revised August 2022

r
■ Complete Items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card toN back of the mailpiece,
or on the front if space permits.
M P. � D'-v. l 130S01"`
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IIIIIIIl�IIII IIIIIIIIIIIIIIIIIII�IIIIIIIIII III
9590 9402 7786 2152 9241 59
7022 3330 0001 7657 8501
PS Form 3811, July 2020 PSN 7530-02-000-9053
A.
Agent
. ReceiaTtiy (fined Name)
C. Date of Delivery
eke
D. Is deli ery address different from Item 17 ❑ Yes „
If YES, enter delivery address below: ❑ No
MAR - 7 2023
S. Service Type
❑ Priority Mail Enpresse
❑ Adult Signature
❑ Registered Mail'-
❑pdUlt Signature Restricted Delivery
❑ fleglstered Mail Restricted
li Codified Mail@
❑ Cerlfged Mail Restricted Delivery
Delivery
❑ Signature Confinatlonv '
❑ Collect on Delivery
❑ Signature Confirmation
❑ Collect on Delivery Restricted Delivery
Restricted Delivery
Insured Mall
Domestic Return Receipt ,

1 �'UAQMP

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