89973A - Janiski

00mk ❑CAMA ❑ DREDGE & FILL
GENERAL PERMIT
ONew []Modification ❑Complete Reissue ❑Partial Reissue
N9 '89973
Previous permit
Date previous permit issued
'A, B C D
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 , I , ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.govfCAMArules
Applicant Name Authorized Agent
Address Project Location (County):
City State ZIP Street Address/State Road/Lot #(s)
Phone # ( )
Email r:\r'Y+fr+i. «.r.+ Subdivision
.. city - ZIP
Affected ❑ cW ❑ EW ❑ PTA ❑ ES Q PTS Adj. Wtr. Body (natfmanfunk)
AEC(s): ❑OEA ❑IHA ❑UW ❑SPIMA ❑PWS Closest Mal. Wtr. Body
ORW: yes/no` PNA: yes/bq)
Type of Project/ Activity ! r� "'� Ca +. � I 1 ".) U �!-> f ct ;
(Scale:j': iA,l )
Shoreline Length
Access Length
Pier (dock) length - -
FixedPlatform(s) -i
Floating Platform(s)
Finger piers)
Total Platform area
Groin length/#
Bulkhead/ Riprap length iT
Avg distance offshore
Breakwater/Sill
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
es no I
SAV observed: Y -
Moratorium: n/a yes no -
Site Photos: yes no - ---I
Riparian Waiver Attached: yes no
A building permit/zoning permit may be required by: > U.n'G &V
Permit Conditions ❑ 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.
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
(Please Initial).
Signature **Please read compliance statement on back of permit**
Application Feels) Check #/Money Order
Signature
Issuing Date
Expiration Date

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RECEIVED
AUG 2 2 2023
N.C. DIVISION OF COASTAL MANAGEMENT - X- P� �
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM1 V P
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:
Mailing Address of Owner. 5 (;L m Q Q. $ "o i% •(•
Owner's email: 1 & rn jam J ki er s Phone#: W 33 — 02 /�
�C�v>7ai i • [owi
Agent's Name: l"dv! t tnCt/ r of `ram AL Agent Phone#: �sr� ' 331
Agent's Email: IaNde.,
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
'�ttom Dortion 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
description or drawing, with dimensions, must be provided with this letter.
k V� 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 ff 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' seetback a
Signature of Adjacent Riparian Property Owner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO:
Mailing Address of ARPO:
ARPO's email:
Date:
ARPO's Phone#:
'waiver is valid for up to one year from ARPO's Signature"
Revised July 2021

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AUG 2 2 2023
N.C. DIVISION OF COASTAL MANAGEMENT DCM—EC
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:
Mailing Address of Owner: t Yl QS CA679VQ.
Owner's email: AMICniSki � wwne �honoe#: y�3'�r2c3"dZ i
Agent's Name: (Gt'dtin f'%'Vrr'jn t t Yol� Agent Phone#:
Agent's Email:
N
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
'atom 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
description or drawing. with dimensions, must be provided with this letter.
t/ 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.G. urvisron 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
Signature of Adjacent Riparian Pro rty Owner
01Ell
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO:
Mailing Address of ARPO:
ARPO's email: ARPO's Phone#:
Date: *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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