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NKCAMA ❑ DREDGE & FILL N° 89939 (2) B C D
GENERAL PERMIT Previous permit
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 11N' / ZW ❑ Rules attached. ® General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name 1 �1 COAX Authorized Agent IY a"fl . Lj (U 12i (1 u
Address a o a 3 I dcdE N Cove. J_r Project Location (County): Lh O 1W1 `0.`yt
City Ecke^.O^ State NC- zip a-1931 Street Address/State Road/Lot #(s) lOT 96
Phone#(��n 1—��tx�5-7(,o ai�.�,l� k4n Clekei,
Email 14��� l\ S co k T tccs l 0- Nnn 6l (. CO tv� Subdivision f'Ln \-64 — 1 k I I
city Ede++f2N zip Z1751
Affected ❑ CW ® EW [T PTA ❑ ES ❑ PTS Adj. Wtr. Body Cho W am Ft V'ti—
c (at non/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑SPIMA ❑ PWS Closest Mal. Wtr. Body
ORW: yes/0 TPNA: y\es/10 ` p1
Type of Project/Activity .LhcW� A I�-t k I 2.' :moo �+
(Scale: i �_ Lid j
r
Shoreline Length '--
Access Length
Pier (dock) length
Fixed Platform(s) ..
Floating Platform(s)
Finger piers)
Total Platform area 1
Groin length/#
Bulkhead/ Riprap length
Avg distance offshore ^
Breakwater/Sill
Max distance/ length
Basin, channel
Cubic yards
Boat ramp `
Boathous Boatli )7-1X ZJ
Beach Bulldozing
Other
SAV observed: yes 4
Moratorium: (a yes no
Site Photos: no
RiparianrianWaiver Attached: yes no
,,t
A building permit/zoning permit may be required by: ',V(1Wqh co,,N
Agent or Applicant PRINTED Name
eTn
Permit Officer's PAINTED Name
�1
I
5�r�cw�
TAR/PAM/NEUSE/BUFFER (circle one)
See note on back regarding River Basin rules
ElSee additional notes/conditions on back
(Please Initial)
Signature -'Please read compliance statement on back of permit"
acm • � 540
Application Fee(s) Check tt/Money Order
Signature ✓1
?/ S71,3 It/ZS/�3
Issuing Date Expiration Date

�`°""x.�❑CAMA ❑ DREDGE & FILL N9 89939 '\ -.- A B C 10
Previous permit
GENERAL PERMIT 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. F1 General Permit Rules available at the following link: www.den.nc.goy/CAMAnules
Applicant Name
City
Phone # ( )
Email
Authorized Agent
Project Location (County):
ZIP Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ CW ❑ EW M PTA ❑ ES ❑ PTS Adj. Wtr. Body - (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/0)
Type of Project/ Activity
(Scale:l'. 1, 1
Access Length
—(
-�"
—
-`---
Pier (dock) length
i
Tr
Fixed Platform(s)
Floating Platform(s)
_
r`{'-
Finger pier(s)
!
I r
Total Platform area
1
I
_
_ i
r—
Groin length/p
Bulkhead/ Riprap length
f
i
Avg distance offshore
T
--
-
Breakwater/Sill
or
Max distance/length
Basin, channel
Cubicyards
Boat ramp
-�
Boathouse/ eoatlik
Beach Bulldozing
Other
SAV observed: Yes no
1
Moratorium: n/a yes no
Site Photos:
�.
j
Riparian Waiver Attached:
L..._.._...
.
A building permit/zoning permit may be required by:
Permit Conditions
C
❑ 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
Application Fee(s) Check R/Money Order Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: c7o :5�o4
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
r.A_ Z,,, -�d y-5 , L . ? 5 3Z
-Yk-z — 1,1700-2 to
ICiSC�T��1
T A-v 1 S
Agent
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: I( f r s�crl
at my property located at 26 f4o JJ-CA L-t-,) -
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 OwAer Information:
Signature
Print or Type Name
wA) P
Title
7/R/la—
Date
This certification is valid through
1 U L 1 9 Z023
L-:s-,w,
( ,kkL, k, fit 8,-) 4�,

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: ahel n % +� 1�-�^©^�J
Address of Property: ��'' 1l R)p ,� `h 6I Np�h.��'°✓�►_ �-
Mailing Address of Owner:o26 01
Owner's email.. i5K4.0 rO rs P oane#'Gb'� :.gq- ®d�
Agent's Name: Agent Phone#:
Agent's Email:
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.
✓ 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
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 some/all of the 15' setback
SignatAdjacent Property Owner
_OR_
-
s
I do not wish to waive the 15' setback requirement (initial the blank)
JUL 1 9 20B
Signature of Adjacent Riparian Property Owner: � �-
Typed/Printed name of ARPO: CEtneA R • 6ne5 1
Mailing Address ofARPO: 3313Shadi Side l-r\. A 03321
ARPO'semail: �QneJ-i Cok.AJ ARPO'sPhone#: 70-4353D36-
Date: 02 *waiver is valid for up to one year from ARPO's Signatyre*
Revised July 2021

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)
1
Name of Property Owner: a� ^ 1y 1^ * L t) j L A In n �' �• "��
Address of Property:
CCU-1 61
Mailing Address of Owner:
J w 's PhonJ '
45
Owner's email:rr?t 1F r %:'� ' nerhone#:f % - O
Agent's Name:
Agent's Email:
Agent
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Ownerl
I hereby certify that I own property adjacent tothe 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.
1/ 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 musr norny me rv.�. ury --, —
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) IJ;. i
Signature of Adjacent Riparian Property Owner: r ��/✓�"�/
r
Typed/Printed name of ARPO: i�%lwrr ��Cr✓ '�
Mailing Address of ARPO: 20- -
ARPO's email: /rcr 60/ a i�-dr d,� rarcry 5 rnuuen: o• t /
i
Date: �� � �� 'waiver is valid for up to one year from ARPO's Signature'
Revised July 2021

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