89974A - Rippin II

,ICOAI ®LAMA ❑ DREDGE & FILL N9 89974 Al, B C D
GENERAL PERMIT Previous permit
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 I ❑ Rules attached. ;w,! General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name
Address
City
Phone # O
State
Affected ❑ CW ❑ E W ❑ PTA
AEC(s): ❑OEA ❑IHA ❑UW
ORW: yes/no PNA: yes/no
Type of Project/ Activity
shnralin I nnvth
ZIP
❑ ES ❑ PTS
❑SPIMA ❑PWS
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Adj. Wtr. Body
Closest Maj. Wtr. Body
(Scale: )
Access Length
Pier(dock)length
—
i
_
){,
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— —
Fixed Platform(s) - f -
Floating Platform(s)
—
—
_
Finger piers)
Total Platform area--
Groin length/#
Bulkhead/Riprap length
Avg distance offshore
�
r
kilt
Breakwater/Sill
I
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_
I
Max distance/length
Basin, channel
Cubic yards �-
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t#
1....
._.
Boat ramp
Boathouse/Boatlift
I
Beach Bulldozing
Other-
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SAV observed: _ yes no
Moratorium: n/a yes no
Site Photos: :yes nor
Riparian Waiver Attached: yes no
---
A building permit/zoning permit may be required by:
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. (Please Initial)
Agent or Applicant PRINTED Name
Signature "Please read compliance statement on backof permit*•
Permit Officer's PRINTED Name
Signature
Application Feels)
Check#/Money Order Issuing Date
Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 11dAwi l_
Mailing Address: of l `1 GC4& i'1&'-c. brL
Phone Number: r)-5 a- Lj C1 - l o S O
Email Address:
WK
I certify that I have authorized CcrgC Pn fN1Lf/ n L + err t- ,
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
10VIX
at my property located at
in AC1,54uo-6,1 L 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 0 Information:
77er,
Signature
Print or Type Name
Title
Date
This certification is valid through /)L- / l5 / 3
RECEIVED
SEP 13 2023
DC!V -EG

RECEIVE..
N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
AUG 2 2 2023
(Top portion to be completed by owner or their agent)
�j // DCM-E�,�
Name of Property Owner: H /rd M 01 / Q 1p;j;,�
Address of Property: 2 -I�)i2, tC,'Fr, tlC 0
Mailing Address of Owner:
Owner's email: Nrd Owner's Phone#:
Agent's Name: t't14a'jn2 . r^L
Agent's Email:
Agent Phone#: a6J--3�i I — &313
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
r
I DO NOT have objections to this proposal. I DO have objections to this proposal.
It you nave objections to what is being proposed, you must notify the NX. 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'
of
to
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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RECEIVED
N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM A116 2 2 2023
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent) DCM-EC
Name of Property Owner: 1q,*!Jt " i (" li •H : n
Address of Property: of (`� 8" t(w DIL bli2 Cri
Mailing Address of Owner:
Owners email: Id/A Owners Phone#: rs1- '-I8`I - I as
Agent's Name: 144dte% t'i l ^ 2 1 n L 'Agent Phone#:
Agent's Email: �Q/ r o�01 yVlarf n [707/1 t(A+ t'
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 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.
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 notny the rv.c. urwsron or wazrar
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 sion
the appropriate blank below.)
I DO wish to waive sometall of the 15' setback
t�
Signal of e t Riparian r party 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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