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,*ENEG
RAL PERMIT
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❑ DREDGE & FILL
GENERAL PERMIT
N° 89986
Previous permit
Date previous permit issued
B C D
® 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 I M , i200 ❑ Rules attached. M General Permit Rules available at the following link: www.deq nc gov/CAMArules
Applicant Name I' wrAct.11
F—Rij
Authorized ,Agent ImViS Lr((4
AddressI1.5 i CM10ro ke
Gr6kk
Project Location (County): Cij10WCLy%
City l=oQ QY\A r' State
NIL
zip 211 3:.
Street Address/State Road/Lot #(s)
Phone #(25z) 33I-0hc)3
I15 Pevhl�roke t`-c.
Email vywr Aall he ll fS Q CyNp, I.
C, oy-\
Subdivision
City [FdeA4xLr, zip 2'7 fp U.
Affected ❑CW ❑EW
®PTA
❑ES ❑
q `
I41�QTQ1�PTS Adj. Wtr. Body ` RI b(4Aj �I�(r®nan/unk)
AEC(s): ❑OEA ❑ IHA
❑ UW
❑SPIMA ❑ PWS
Closest Mal. Wtr. Body eWI&rIC S0(, 1I
Al b
ORW: yes/5 PNA: yes/0
Type of Project/ Activity
Access Length `c'
Pier (dock) length / / Y �f
Fixed Platform(s)
Ff berrFi
flil(nCt1-aTi¢
ScN �d
Floating Platform(s)
Finger pier(s) ^
Total Platform area
Groin length/#
Bulkhead/ Riprap length '—
Avgdistanceoffshore
Breakwater/Sill —'
Max distance/length
Basin, channel
Cubic yards
Boat ramp
Boathouse oatli
Beach Bulldozing ^-
Other f��/6r�� � J
0
r�1r
Q� \ X
<, {\N
�'G ,Po
j 't
ll/ ® �l`�a \lP
V\
SAV observed: yes GO
Moratorium: es no
Site Photos: no C W°'s>I
Riparian Waiver Attached: es no �rI
A building permit/zoning permit may be required by: C �4S t..R>Lv� co". to
Permit Conditions
Agent or Applicant PRINTED Name
Permit Officer's PRINTED Name
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
(Please Initial)
Signature "Please read compliance statement on back of permit" Signature(
$�c�, �=' P4oy /-3I
Application Feels) Check#/Money Order Issuing Date
t1/3o/
Expiration Date

❑,CAMA ❑ DREDGE & FILL N9 89986 A> B C D.
Previous permit
i :GENERAL PERMIT Date previous permit issued
y, 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: wwwdeq.nc.gov/CAMArules
Applicant Name _
Address
City
Phone # ( )
Email
State ZIP
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ cW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Won Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
Shoreline Length
Access Length
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Total Platform area
Groin length/#
Bulkhead/ Riprap length
Avg distance offshore
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
SAV observed: yes no
Moratorium: n/a yes no
Site Photos: yes no
Riparian Waiver Attached: yes no
A building permit/zoning permit may be required
Permit Conditions
(Scale:` )
❑ 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"
Application Feels)
Signature
Check q/Money Order Issuing Date
Expiration Date

exualm, Im
Name of Property Owner Requesting Permit: ! ' GiJ 1 h a ( &j
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
�2--71
2S2 - 01g?
to act on my behalf, for the purpose of applying for and obtaining all LAMA permits
necessary for the following proposed development: i" f�; i 14 L' , J � Oa �
"- I y,tkLC,jI j6L,k irk )n �VrAEfCn&j
at my property located at 115 .r4 ( { r~ d?,h^,dC. f
7kZ in L � j U✓iyrl . County, L
t furthermore certify that 1 am authorized to grant, and do in fact grant permission !a
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:
C
•j nature
Print or Type Name
VW'I L
Title
Date
This certification is valid through — 7—1 L 1 261
JUL 13 2023
DCM-EC

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENTRIPARIAN iDA , RETURN RECEIPT E EIPT REOSTED or CERTIFIED MAIIVER Rr
i/ f�
(Top portio [n�to be
completed by owner or their agent) JUL 13 2023
Name of Property Owner , +tr✓ (fn 5 (( (� » I
Address of Property (�S @'��rkt � t(� DCM- C
Marling Address of Owner.
owner'semail:.!"�rs�w(���1M,7�>*
Agent's Name �f hv: 5
Agent'sEmail: ,g}rvch��tL
Phone# - 3 � 0 9
Agent Phone#: 7 52 — j L? C "1 i
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Prgpertv Owner)
I hereby certify that I own property adjacent to the above referenced property.'rhe individual applying for this
permit has described to me, as shown on the attached drawing, the development they are proposing. A
100 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 he
contacted at [phone]. No response is considered the some as no objection if you have been
notified by Certified Mail,
NV11Tl:11A6U 1
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be sat back a minimum distance of 15' from my area of riparian access unless waived by me
(this does not apply to bulkheads or nprap revetments) (If you wish to warve the setback, you must siq
the appropriate blank below.)
100 wish to waive some/all of the 15' setback
SigrenatuAdjacent Pofarian Property Owner
-OR.
I do not wish to warve the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner —
Typed/Printed name of ARPO:
Mailing Address ofARPO:©t L Gircf?iE 1Jf.QC.�7ort /t%CJ
ARPO'semail:at9�i+SDnoZ7T �r AARPO'sPh ne#: 22'(-©a?j
Date: ! 6 waiver is valid for up to one year from ARPO's Signature'
Revised July 2024

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:
Address of Property:
bd
(,$ Pembroke Circle,Pdenton,NC27932
Mailing Address of Owner:_ 1 �'tISMi<e L'rcja_ d, fy „j "j
Owner'semail: _ A;/_t;r,Owner'sPhone#= .-ON
Agent's Name:
Agent's Email:
Agent Phone#:2- - W7 - 5 z
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacqnj erogegy 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. R
descriotbn 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 nottly, 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, 27.909. DCM representatives can also be
contacted at (252) 2"3901. 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 ell
the appropriate blank below.)
I DO wish to waive someiall of the 15' setback
_OR_ _..__..
Signature_ of Adjacent Riparian Pr perry Owner
_'..
I do not wish to waive the 15' setback requirement (initial the blank)
l U L 1 3 2023
Signature of Adjacent Riparian Property Owner: _,
lt3::
TypedlPrinted name of ARPO: Donna Chaney
Mailing Address of ARPO: 7436 Spout Bill Road, Sykesvilic, Mil 21784
ARPO's email: dure761 I t&comcas,t.net ARPO's Phone#: [phone]
Date: _ 71612023 'valuer Is valid for up to one year from ARPO's Signature*
Revised July 2021

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