89616A - Green

❑CAMA ❑ DREDGE & FILL N9 89616 V (,DB C D
ENERAL PERMIT 0-Previous permit
t 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:
15A NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name r s-'Y:_ _(! Cr, Authorized Agent N Q 0 ttekd'l2 rr l i` V kA ir'l I:r •: i t r..
Address gg Project Location (County): 1>1,✓i
City State ZIP { `1/t y`! Street Address/State Roads/Lot #(ss)) � J) ~T. ✓ �� y(' {�
Phone#(—) fli' .s�z L(� 7%I„�,' ff'[ 11, •�
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Email Subdivision
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City ,. {.. rr r ZIP
Affected ❑cW DEW ❑PTA ❑ES ❑,PTS Adj. Wtr. Body �axt YJ r)edU P' e:-y (nat/man/unk)
AEC(s): ❑OEA ❑IHA ❑UW SPIMA f❑PWS
Closest Maj. Wtr. Body !
ORW: yes/no ` PNA: yes/no
Type of Project/ Activity
(Scale: 1
Shnraline I Pneth `
Access Length
Pier lengthO
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ti+
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:.. t
-j-
;jp+�-•
.�1(t
7)
Ny�j'('{I�II�
8
Y
—
(dock)
Fixed Platform(s)"`
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i
r
Floating Platform(s)
;T
—
—
)y��yV'
-
-
finger piers)
i
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—�
I
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Total Platform area
Groin length/#
i
- .....
_
--
Bulkhead/Riprap length '. •��
—
1-
i-.�
_
__I_
f.f-—
�-
—_
-__
Avg distance offshore
;
Breakwater/Sill_^
{
Max distance/ length J..,.
Basin,channel
-
l-
-
i
'°F°
-
-�L
I
I
Cubic yards
'-Vt
Boat ramp
1,,
I'
—t_
—
_
—
-�-
--
J -
use/
Boathouse eoatlift
-
I
Beach nn g
j--
--•---��
-
._-__._
__
—..--_
___.__
SAVobserved: yes no
Moratorium: -n/a yes no
Site Photos: yes no-
RiparianWaiverAttached: yes no
A building permit/zoning permit may be required
by:
icsW
V%
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Permit Conditions
u IAIvrAM/NI:Uat/t5UrrtK(C1rcle one)
❑ See note on back regarding River Basin rules
.L*t'' n vn�t. v..l vvo Ld.ea-a...0�..ff{^3'i f.,�F., ❑ 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 orApplicant PRINTED Name Permit Officer's PRINTED Name
Signature *'Please read compliance statement on back of permit" Signature
�gagg
Application Fee(s) Check #/Money Order Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Req
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized 1\i( �k'� 1 ( Ji C t�Mar 1 tiy-
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at ,
in �,�county.
I furthermore certify that 1 am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature RECEIVED
Print or Type Name MAR 2 1 2923
Title
ICI DW3
Date
This certification is valid through'" -
Revised Mar. 2016

N.C. DMSION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMfAIVER FORM
CERTIFIED MAIL RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top
Name of Property Owner:
Address of Property:
Mailing Address of Owner:
to be completed by owner or their agent)
Owner's email:I�
Agent's Name:V \1 E- c fl i i -t
Agent's Email:
Owner's Phone#: 25�CJ1�X)
Agent Phone#:�w - Q1 "
P
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
Bottom portion to be completed by the Adjacent Progertv Owners
L
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
descri tion or in wkh dimensi ns ust be rovided w this letter. �)00
1. X 2 nC er t e�� 10
DO O? have objections to is roposal. 1 DO1 ave objections to this proposal.
fovebetons 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. Grfffln 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
1 '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 sometall 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
TypedtPrinted name of ARP(
Mailing Address of ARPO: _
ARPO's email:
Date:
Owner:
ARPO's Phone#:
jt l �rS�G i
'waiver is valid for up to one year from ARPO's Signature*
R E C d V� n Revised May 2021
MAR 2 1 2023
d1
m
DCM-E,

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: ' `C I )
Address of Property: y ,o ` t ay- K�� {� K (.-DV K, \. j
Mailing Address of Owner: `-i L 3 � . nn t t (� j� z -7Q f-� Cl
Owner's email: Y—etfl q' C "Ge coffbwnees Phone#: ref J
1 Agent Pho``Lo
)u6,(26 ne#: �� J�
Agent's Email;m{) .ir1 e manc co t i s-S . c-UV y,
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
descri tion or drawl with dimension ust be rovitl d with thi etter ;
�1�� u� �cr a rc: -,ems Q XZz hr�erj�ters� lua000l�
` O NOT have objections to this proposal. I DO have objections to this proposal. 1 ��
If you have objections to what is being proposed, you must notify the N.C. Division of Coastal L'V .✓
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Gruen 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 riorao 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- ,
Y`
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian
Typed/Printed name of ARPO:/ �a- Z
1Zt;
Mailing Address of ARPO;; 14 60 1 I t f VLt lZ t }�Cic r,—y to voi j c (q 4 �1
ARPO's emailA e#:4 7 L 6
73 ;
Date: 3 f 0 2 *waiver is valid for up to one year from �ARPO's Signature*
MAR 2 1 2023
Revised August 2022
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