86956A - McLean

1000WA`",ar�❑CAMA ❑ DREDGE & FILL N° 86956 f, A B C D
GENERAL PERMIT Previous permit ffil 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:
I SA NCAC ❑ Rules attached. ❑` General Permit Rules available at the following link: www.deo nc gov/CAMArules
Applicant Name
Authorized Agent ' : ' -I -.. r
Address
Project Location (County):
City. State _
ZIP
Street Address/State Road/Lot#(s)_
Phone # (r '.• .,)
Email
Subdivision
City ZIP
Affected ❑CW ❑EW MPTA
❑ES ❑PTS
Adj. Wtr. Body (nat//nan/unk)
AEC(s): ❑IDEA ❑IHA ❑UW
SPIMA ❑PWS
Closest Mal. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
(Scale:
Shoreline Length
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Permit Conditions 12, q.
Agent or Applicant PRINTED Name
Signature "Please read compliance statement on back of permit**
1
Permit Officer's PRINTED Name
Signature
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
(Please
Feels) Check#/Money Order Issuing Date
Expiration Date

A¢ency Form For Permit Applications
1, Richard McLean,
(property owner)
the owner(s) of the property located:
Adjacent to the Currituck Sound:
163 Simpson Road, Barco Currituck County North Carolina,
(property location/address)
do hereby authorize: SAMPSON CONTRACTING, INC., and its agents (Theodore
Sampson, or others) to act as my agent for the purpose of obtaining any environmental
Permits, including, but not limited to NC Coastal Area Management Act permits, NC
Dredge and Fill Act permits, NC DEQ permits, US Army Corps of Engineers permits,
and/or any local, or county building and environmental permits, that may be associated
with the development at the above -indicated property, which entails:
Modification and enlargement of pier, platforms docks and water dependent structures
within waters that are adjacent to the property identified above
(describe the proposed development for which permits are being sought)
This agency authorization is limited to the specific activities described above_, and will
expire on:
1 April 2023, unless withdrawn in writing prior to that time
(date on which agency authorization expires)
(Agent Information:)
Sampson Contracting, Inc.
125 Hunters Trail West
Elizabeth City, NC 27909
Tel.: [phone]
[e-mail]
(Property Owner Information:)
�y 416I202222
9 September 2021
(signature) (date)
Richard McLean 163 Simpson Rd
(printed name of owner) (Mailing Address)
Barco NC 27917
(City, State, Zip Code)
757-645-5471
(Telephone Number)

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Richard McLean
Mailing Address: 163 Simpson Rd
Barco NC 27917
Phone Number: 757-645-5471
Email Address: Kitesurf4ever(aD-yahoo.com
I certify that I have authorized _Sampson Contracting Inc. & Theodore Sampson ,
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: _pier, platforms, docks and
water dependent structures within adjacent waters
at my property located at 163 Simpson Road, Barco, NC 27917
in Currituck County.
1 furthermore certify that I 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
Richard McLean
Print or Type Name
Owne
Title
03 / 23 / 2022
Date
This certification is valid through 04 / o1 / 2o23

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM
CERTIFIED MAIL •RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: Richard McLean
Address of Property: 163
Mailing Address of Owner. 163 Simpson Road Barco NC 27927
Owner's email: kitesurf4ever(a)vahoo.com Owner's Phone#: [phone]
Agent's Name: Theodore Sampson Agent Phone#: [phone]
Agent's Email: tedsr(a)sampsoncontracting com
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
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. Griltn 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 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.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
-OR-
I do not with to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner: '4 c
Typed/Printed name of ARPO: Lyle and/or Abi d Hancock
Mailing Address of ARQPO:p 165 Simpson Road, Barco. NC 27917
ARPO's email: J AGIS �l,`rl1 f5/s�ai�' RPO s Phone#: 02'<g
Date: a 5 Z 94' 9U96aiver is valid for up to one year from ARPO's Signature"
Revised July 2021

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: Richard Mclean
Address of Property: 163 Simpson Rgad Barco NC
Mailing Address of Owner: 163 Simpson Road, Barco NC 27927
Owner's email: kitesurf4everto'�.yahoo.com Owner's Phone#: [phone]
Agent's Name: Theodore Sampson Agent Phone#: [phone]
Agent's Email: tedsr(c)sampsoncontracting.com
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
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)
41
Signature of Adjacent Riparian Property Owner:
TypediPrinted name of ARPO: Zane and/or Lyman Basnight
Mailing Address of ARPO: 200 South Currituck Road, Currituck NC 27929
ARPO's email: ARPO's Phone#:
Date: ra *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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