89677A - Jardiniano

N9 89677
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a GPrevious permit
ENERAL PERMIT 1t
� 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. E] General Permit Rules available at the following link: wwwdeo nc gov/CAMArules
Applicant Name _
Address
City
Phone # ( )
Email
State ZIP
Affected FJCW EW PTA n ES PTs
AEC(s): F—IOEA ElIHA EluW OSPIMA F-1PWs
ORW: yes/no PNA: yes/dq
Type of Project/ Activity
Shoreline Leneth
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Adj. Wtr. Body
Closest Maj. Wtr. Body
P
(Scale: )
Access Length
Pier (dock) length
Fixed Platform(s)
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IN
Floating Platform(s)
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Finger pier(s)
Total Platform area
Groin length/#
MEMO
Bulkhead/ Riprap length
SMEE
Avg distance offshore_
Max distance/ length
channel
Cubic yards
ramp
Boathouse/ Boatlift■■N■■■■■■■■■■
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A building permit/zoning permit maybe required by: -
Permit Conditions TARJPAM/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) .n"1
4_
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit•"
Application Feels)
Signature
Check #/Money Order Issuing Date
Expiration Date

RECEIVED
APR 2 4 2023
lJCM-EC
N.C- DIVISION OF COASTAL MANAGEMENT
rIJACENT RIPARIAN PROPERTY OWNER NOTIFICATION(WAIVER FORM
=TFiED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner. /u a CT JGl / Vl f Cr U -0
Address of Property:
Mailing Address of Owner _
W a &7' ✓'/.�
Owner's email: .1
7r•1 rc Vf,(rc�
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�aILY vL4c/, (Nvt �S r-�7ii-�%L�
/ Owne s Phone#: 2
Agent's Name: I « y cle, M ur�� F/ �L ' I LAgent Phone#:�s� 3
Agent's Email: lcr4y al I%%r�rirc�% lkT /✓t�/• /•C(?o2t
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacerd Property Owner)
I hereby certify that I own property adjacent to the above refarenceuproperty. The individual applying forthis
permit has described to me, as shdwn on the attached drawing, the development they are proposing. A
description or drawing with dimensions must be provided with this letter.
x 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 16 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' setba
'a��-
Signature of Adjacent Riparian Property Owner
-OR-
41I 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'

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RECEIVED
APR 2 4 2023
DCM-EC

RECEIVED
APR 2 4 2023
DI. M-EC
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_ ✓t i 6" fw
1
Address of Property: �� % V!
Mailing Address of Owner. S C lly�-i
'' w 7— r, v 6d I A @- A�' t NI �, t r m 7 S` 7- 7 2 6 '3
Owner's email: 11J Owner's Phone#: c' J
Agent's Name: `u''t1t fv y''tMEY ,J, - Agent Phone#:
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacent Property Owner)
1 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 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 19 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/ail of the 15' setback "
Signature of Adjacent Riparian Property Owner
-OR-
lK 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'

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RECEIVED
APR 2 4 2023
DCM-EC
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