89792A - Lay

❑CAMA ❑ DREDGE & FILL NU 89792 A B C D
GENERAL PERMIT Previous permit
Date previous permit issued
New ElModification ❑ 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. Ef General Permit Rules available at the following link: www.deq.nagov/CAMArules
Applicant Name Authorized Agent i.
Address Project Location (County):
City State ZIP Street Address/State Road/Lot #(s)
Phone # ( )
Email Subdivision
City r) r_. P'.: ZIP T
Affected ❑ CW EJEW 0 PTA ❑ ES ❑ PTS Adj. Won Body L) !� I i- �v . _L =. (nat/man/unk)
AEC(s): ❑OEA ❑IHA ❑UW ❑SPIMA ❑PWS Closest Maj. Wtr. Body -I,
ORW: yes/qy PNA: yes/6
Type of Project/ Activity 1—
Shoreline Length
Access Length ,
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Total Platform area
Groin length/# I --
Bulkhead/Riprap length f
Avg distance offshore --
Breakwater/Sill �-
Max distance/ length /(
Basin, channel
Cubic yards v4
Boat ramp r
Boathouse/,Boatlih i
Beach Bulldozing s
Other
SAV observed: yes no --
Moratorium: n/a . yes no
Site Photos: 'eyesno
Riparian Waiver Attached: : yes no
A building permit/zoning permit may be required by:
Permit Conditions
(scale: i )
4 k l :_.. A_e.:.. I I I1... , I.
❑ 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
Permit Officer's PRINTED Name
Signature**Please read compliance statement on back of permit** Signature
i
Application Feels) Check #/Money Order Issuing Date Expiration Date

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date J�
Name of Pro erty, Owner Applying for Permit:
Mailing Address:
—LVO (n1A±nL5 �� (`rl� k logy_
.27i5b
I certlf}v that I have authorized (agent) Lauren Berry Burch
to act on my
behalf, for the purpose of applying for and obtaining all CANNA Permits necessary to
install or construct (activity) �,
at (my property located at)
This certification is valid thru (date)
Property Owner Signature -- Date

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 Propeq Owner: Charles Loy
Address of Pro erty: 116 Walers Drive Mogock
Property -
Mailing Address of Owner:
Owner's email: Owners Phone#:
Agent's Name: Lauren Berry Burch 252-339-3846
Agent Phone#:
Agent's Email: Capsm8rire@embargmai1cone
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 e be provided with this lettr.
\,ioI DO NOT have objections to this proposal I DO have objections to this proposal.
It you nave 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 IF from my area of ripadan 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.)
DO wish to waive somefall 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 Owner:
Typed/Printed name of ARPO:
Mailing Address of ARPO:
ARPO's email: ARPO's Phone#:
Date: Lo1� o: lo2 s . waiver is valid for up to one year from ARPO's Signature`
Revised August 2022

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)
Charms Loy
Name of Property Owner:
? 1F, t'Mler- Drive k4oVork
Address of Property:
Mailing Address of Owner:
Owner's email: Owners Phone#:
Agent's Name: i.a°rep Berry Burch Agent Phone#: [phone]E46
Agent's Email: Caps=iadnearnbargmaii uon;
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent 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.
1 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 nodiy 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 riprao 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'selback /mot A t k S.�.?..»r
Signature of AdWent Riparan Prope Owner
-OR-
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: IVI I C 9t /'7C L C'7- )1A /W 4Q G.-Y'/r
Mailing Address of ARPO: fr/ C�/ GJ,/�' // A_�[ �j s4 j7�61r, -Z/'� t fJ IJ
ARPO's email, 'D D6 ARPO 's Phone#:
Date: �J �.� .2!%! afver Is valid forupto one year from ARPO's Signature'
Revised August 2022

HER M
is OR
Owner Name
Owner Name 2
Owner Name 3
Billing Address
Billing Address
-ontinued
Billing City
Biking state
Billma ZIP Code
Construct a walkway 5'x60' with a T Platform 10' X 12'
(t/-) 45 feet from the property line
12' X 12' Boatlift

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