89825A - Warden

``°"'" ❑CAMA El DREDGE & FILL N9 89825 ',A B c D
GENERAL PERMIT Previous permit
i Date previous permit issued
0 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.deq.nc goy/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 Mal. Wtr. 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/p
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/Sill
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 by:
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 Fee(s)
Signature
Check q/Money Order Issuing Date
Expiration Date

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N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY I
(Top portion to be completed by owner or their agent) I)>
1 77�i�I� ,
Name of Property Owner: �1-- C21 C " �:!i--\ rw ��
Address of Property: _
Mailing Address of Owner:
Owner's emai
Agent's Name:
Agent's Email:
tr1e— , Cc— r-N
Or ALk) n/ C a193a
_ 1512 1Aoc [w-D
Phone#: Z SSG
Agent Phone#:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adlacent 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
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 mu. urwsron or coasrar
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 RE C IV
V i• D
Signature of Adjacent Riparian Property Owner
-OR SEP 13 2023
1 do not wish to waive the 15' setback requirement (initial the blank)
DCM—EC
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPlOO: n �n /\ Ltd t rtiw
Mailing Address of ARPO: `��� i`'W9, am, L 2-0-0
ARPOos mall:�1 Mj �W ARPO's Phone#:
Date: �—Lt^ 9 D �:4 *waiver 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: LZi C L_k poj .J C. \,J Q_ w
Address of Property: i bC-
Mailing Address of Owner.
2-
Owner's email:�4 -4m�
�b_,-,
t_-,C4--nOwner's Phone#:—(S'7 ZGI
- $:SQ_40(
Agent's Name:
Agent's Email:
Agent
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
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- RECEIVED
I do not wish to waive the 15' setback requirement (initial the blank) 1�_ SEP 1 3 2023
Signature of Adjacent Riparian Property Owner:
Typed/Printed name ofARPO: 0, � _ 1 oNr�JG _511l�/>Z1 ��Y �/ IVp
Mailing Address of ARPO: � S-
1 e r�,at2
1 el—
ARPO's,JARPO's Phone#: -S S �(F /
Date: 9/ 2=/ZS *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

SEP 1 3 2023

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