87013A - Miller, Jr

'At°"rw ❑CAMA El DREDGE & FILL lei 87013 A B C D
GENERAL PERMIT Previous permit
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:
i SA NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: vvmvdelLm; goy/CAMArules
Applicant Name Authorized Agent
Address Project Location (County):
City State ZIP Street Address/State Road/Lot#(s)
Phone # ( )
Email Subdivision
City ZIP
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (fiat/ nardunk)
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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Groin length/#
Bulkhead/ Riprap length
Avg distance offshore
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A building permit/zoning permit maybe required by:
Permit Conditions
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/mnditions 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
i.
Application Fee(s) Check M/Money Order Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
p�
Name of Property Owner Requesting Permit: .T i'l Ir l- / F /Z
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
J AltlLLct- 15a1)01 L"'
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Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: &Yaliliq 6A, L6✓/ e er
at my property located at
in County.
/ furthermore certify that I 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 Owner Information:
rnnr or r ype rvame
C�wger
Title
/l // / A-.
Date
This certification is valid through /4i / // / Z�

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: T
Address of Property: .) 111dIM7 / lane-/ Cry �/1 �"c-
Mailing Address of Owner:
i
< <2
Owner's email: � h ��- �w\ 1 or^'I Owner's Phone#: 2� —
�
Agent's Name: �/PZ&R -P Agent Phone#:
Agent's Email Cl 0,�Cj
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.
64-1 1 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
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' setbac% / —
Sign-ature of Adjacent Riparian Property Owner
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's email:
Date:
Phone#: a C2 3573
"waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

H M,11iz c /95 loin/ f-/3!� /a7e_

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: �Tfl t' I r (1p4 OR
Address of Prol
Mailing Addres:
Owner's email:
Agent's Name:
Agent's Email:.
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(_Bottom portion to be completed by the Adiacent Property Ownerl
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
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 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 blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: JQ
Mailing Address of ARPO: 'I 7-2
ARPO's email:
-in5l-,e
ARPO's Phone#: 2S Z — 33`1-'� I b'
Date: /0 2- Z _*waiver is valid for up to one year from ARPO's Signature*
2 "v
Revised July 2021

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