89859A - Settles

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]CAMA 0 DREDGE & FILL ^ B c D
a GENERAL PERMIT Previous permit
3 Date previous permit issued
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:
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15A NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: wwwdeq nc gov/CAMArules
Applicant Name h
Address I
City States ZIP
Phone#('—i)
Email
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. Wtr. Body
ORW: yes/no. PNA: yes/no,
Type of Project/ Activity
(Scale: )
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Access Length
Pier (dock) length
Fixed Platform(s)
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Floating Platform(s)
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Finger piers)
Total Platform area
Groin length/#
Bulkhead/Riprap length -ri
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Avgdistanceoffshore
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Breakwater/Sill
1
Max distance/length
Basin, channel
Cubicyards
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1
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Boat ramp
Boathouse/Boatlift
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Beach Bulldozing
Other
SAV observed: yes no
Moratorium: n/a yes no
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Site Photos: yes na
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Riparian Waiver Attached: ves 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 Permit Officer's PRINTED Name
Signature **Please read compliance statement on back of permit** Signature
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Application Feels) Check #/Money Order Issuing Date Expiration Date

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: Ar"i D ;
Address of Property:
Mailing Address of Owner:
Owner's email:
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Owner's Phone#: f LSr`-t - L' 1 ��
Agent's Name: (GtAEl1Prt tq&d-Jgtr 37.11C-- Agent Phone#as 1�-3a' ' 112313
Agent's Email: 14q Wdo'n rV1fA �e� F✓IA•�• Coen,
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacent 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.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 revelments). (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 f5' 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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