89970A - Stevenson

JAIdomr" OCAMA ❑ DREDGE & FILL N9 89970 A B c
GENERAL PERMIT Previous permit
Date previous permit issued
X❑ 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. ❑ General Permit Rules available at the following link: wwwd nc pov/CAMArules
Applicant Name
Address
City - State
Phone # ( )
Email
P
Authorized Agent }
Project Location (County): 4 i.,
StreetAddress/State Road/Lot #(s)
Subdivision
City
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wen Body (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/,no,:
Type of Project/ Activity
(Scale:; ' )
ct...rellne Len
Access Length
j
-
j
-
S,
-�-
-
-I
---
Pier (dock) length
or
FixedPlatform(s)
1
Floating Platforms)'
Finger piers)
i
Total Platform area
Groin length/q
OI'Q.
n
Bulkhead/Riprap length
Avg distance
--_I--
---
—
--t
offshore
Breakwater/Sill
.�'
Max distance/length
I
--
4-
I
Basin, channel
Cubicyards
Cubic
Boat ramp
Boathouse/ Boatlift
L
t
j
Beach Bulldozing
Other
I
J,,T
—
SAV observed: yes no
Moratorium: n/a yes no
I
__
_
_
4
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Site Photos: yes no
Riparian Waiver Attached: ves no
A building permit/zoning permit may be required by:
Permit Conditions
OF STATUTES. CRC RULES AND CONDITIONS THAT APPLY TO THIS
Agent: or Applicant PRINTED Narhe
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)
C)'
Signature "Please read compliance statement on back of permit**
Application Feels) Check p/Money Order
Signature
Issuing Date
Expiration Date

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date 6 t?— ^Z 3
Name of Property Owner Applying for Permit:
Pak( L s cS�v'erNsoh
Mailing Address:
?+\fers 6 r-e RA
I certify that I have authorized (agent) ��o✓�� to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) N C-(, j
ioA +
(4L 4
at (my property located at) )0(2,
Z
7 90
This certification is valid thru (date)
� (2 /23
Property Owner Signdjue 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 Property Owner. i ajt( L'
0^
pp
Address of Property: IOj4 I�IYe6kolIrP n Eli2-464 Cii NC 2T101
Mailing Address of Owner: 10 0- g1'Ver'sk0re P Eh0( veK Cyr Oc 27101
1
Owners email: pIS�e� Jetwov O ldmA4•"m Owner's Phone#: (259) 10T�-- 5062 Agent's Name: Agent Phone#:( (n� — �4 Z-6-0/ �l
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom Portion to be completed by the Adjacent Property Owner)
I hereby certify that I own property adjacentto the above referenced property. The individual applying forthis
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 proposes, you musr noury me mi— Limmun ut wastal
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 riorap 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 blanQ) t-S
Signature of Adjacent Riparian Property Owner:
TypedlPrinted name of ARPO:
Mailing Address of ARPO:
f
ARPO's Phone#: C2-5� 202 -5 062-
r
Date: � A_ 7_� 'waiver is valid for up to one year from ARPO's Signature`
v
rL
Revised August 2022

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONNVAIVER 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:
.,r 1. rIASav JTey-evy5on
Mailing Address of Owner. IIJ I -f IM yer 5 norms "'
Owner's email: Owner's Phone#: 1y 52// p/ l
Agent's Name: Agent Phone#:( �0 —(off b ✓O o
Agent's Email:
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
_ - '-"--
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.U. urvrsron or wdbrat
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 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
No
I DO NOT wish to waive the 15' setback requirement (initial the bla
Signature of Adjacent Riparian Property Owner:
TypedlPrinted name of
Mailing Address of ARPO:
v
N
Lf-yIN�-Z:-790 1
ARPO'semail: -Sf J�= _AMA` A PO's Phone#: z5� -&a 7J73�j`�
Date: 4 4�/-7d-Z-� 'waiver is valid for up to one year from ARPO's Signature`
Revised August 2022

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