89923A - Rose

>^', CAMA ❑ DREDGE & FILL N9 89923. A j B C D
a GENERAL PERMIT Previous permit
a 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. N General Permit Rules available at the following link: wwwdeq.nc.gov/CAMArules
Applicant Name
Address
City State
Phone # ( )
Email .
Affected ❑ CW 0 EW ❑ PTA
AEC(s): ❑ OEA ❑ IHA ❑ UW
ORW: yes/no PNA: yes/no
❑ ES ❑ PTS
❑ SPIMA ❑ PWS
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Adj. Wtr. Body i l i
i
Closest Mal. Wtr. Body -
i t t
Type of Project/ Activity �. `�'-7 2 e:. Yc 0-11id
(Scale:
Access Length •i'•••✓ L -
A
-
r-}
1
-
---
Pier (dock) length )t
Fixed Platform(s) � '
!_
...I
�
!
��«a.
Floating Platform(s)
-
-
Finger Piers
1's.
rd-
Total Platform area
Groin length/ft -
--
-
-
_-.
.e
1I
Bulkhead/Riprap length
Avg distance offshore
-
-
-
-
-
-
-I-
-I--
-
-
-i
-
-
Breakwater/Sill-
-
-
-
-
4
-
Maxdistance/length
-
-'-
Basin, channelCubic yards-
.-
Boat ramp
Boathouse/ Boatlift { %2'] EI-� I 1`
"�
`(e
..-.
-t
h
Beach Bulldozing
_
_O
_
Other
SAV
ww
nk+
i
i •'
/
i
of
observed: yes
Moratorium:
Site Photos: yes no 1' CY )' l i }�'
IIV
TT
4
+
'
plk
l
)
t J
-
fry
RioaanWaiver Attached: yes no I
A building permit/zoning permit may be required by: •-- rl c.)G�
Permit Conditions .'-�.t� I•i�C'++.� c-, i�.-t
❑ 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
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature **Please read compliance statement on back of Permit' Signature
.r a{.77
Application Feels) Check M/Money Order Issuing Date
Date

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vil
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DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONlWAIVER FORM
CERTIFIED MAIL' RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Owner: R ovk A- t— Sal r .5p- ` Address of Property: ' q S
(Lot or Street #, Street or Road, City & County) r
Agent's Name A
Agent's phone #:
Mailing Address:
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.
.11 I have no objections to this proposal. I have objections to this proposal.
ff you have objections to what is being proposed, you must notify the 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, Hizabeth City, NC, 27909. DCM representatives can also be contacted at (252) 264-
3901. No response is considered the same as no objection if you have been notifted byCertified Mail.
WAIVER SECTION
I understand that a 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. (If you wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Information)
P,9ri$ntt orTypee Name g
Mailing Address
CULMI, � C�,c, §�) �, �-)-j
City/State2ip
?-92--333--5bg0/r-6An 05e
Telephone Number/Email Address `
(Adjacent Property Owner Information)
1 � ^
.S'Ignntll ' iJ
C i t721 I \C 41
Print or Type Name
Mailing Address
Citylstatezzip
Telephone Number/ Email Address
Date Date*
`Valid for one calendar year after signature" Revised Jan. 2017

■ 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 to the back of the mailplece,
or on the front If soave Dermite.
SC oTi �jj3�. �i Oyk vtntun MN"
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Cus�l4L4,1L1 N i�9y;
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9590 9402 7485 2055 2033 79
7o01/ --�'7l 0 - 0602-qQZ7 - (
PS Form 3811, July 2020 PSN 7530-02-000-90 33
X / , ' ❑ Agent
❑ Addressee
S. Re veil y (Ponied yjme) I C, Date of Delivery
D. Is dellv¢ry add({ss�d'dferent from item t? ❑ Ye;
If YES, en r delivery address below. ❑ No
3I'LS[23
3. SerAce Type
❑ Adutt Slgreture
❑ Adult Signature Restricted Delivery
❑ CeAlOed Made
❑ Cerdeed Melt Restricted Delivery
❑ Collect on DeWery
❑ Doi W on Delivery Restricted DeYv
❑n Insured Mall
T insured Mae Restricted Delivery
1 21 P to
❑ NoAtyMel] Express®
❑ Registered Meilre
❑ R sttered Mau RestActed
Dalvey
❑ signal" Connrraawn^
❑ Signature Conf nnaWn
Restricted Delivery
Domestic Return Recelpt

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