92538C - Martin, Joseph

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ieruascy 1,X]CAMA ❑ DREDGE & FILL , .'._,{ A B Cef }D
GENERAL PERMIT Previous permit
i.
Date previous permit issued
; PS004::4 gi New [1 Modification I _1 Complete Reissue Li Partial Reissue
As authorized by the State of N Carolina,.Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
I SA NCAC.__...__71-- .I W(,) Li Rules attached. Cl General Permit Rules available at the following link:wwvwidgq,BS oy/CAMAJes�F
!I /f �J .Le" _
Applicant Name c /,, _I-- ' Authorized Agent ",10/1/f�' -1 P�µ() (L 1.' ]`. ) t.
AddreZss _ l _ Project Location(County): ,�( '��'l 1,r'`--
City . �f State_ t' j l V �__ZlP )1�,-' Street Address/State Road/Lot/{s)_
Phone#r ) : ` r,' . �—.� ____ �l ( )0 (1,11C ,LVi( L) 7-1--z—
Email �`- 5ubdivisicrv_, J__ ��� ,� -
Chy.__�/1....h r).:�. c 4•(.- _ZIP t9i ` 's
t
Affected Dew j EW NAPTA [ ES rim AI.Wtr.Body-_ 1%'t.l 9 Jj ,_(rwt/nyn/
AEC(s). E OEA _]IHA UW [I SPIMA LI tr.
[� PWS Closest Maj.W Body •j ..1"i i t t. ( Picly)di t i ;,,i;ii?)ci
ORW Y .. PNA:Pno
Type of Project/Activity � t�'LU111%Ltut Sp k k.)1'�1 / Vc tuti�
t ri r _ ` " m,41 s `' N.---- scale:f 1l 3 fj)
Shoreline Length 't•) _ PriLliL� �r,r✓n 7(•
• 1
Access Length """"' , ,� t t/
Pier(dock)length IX r ' T 01
� 7� , tJ X
Fixed Platform(s) Q,)(J j • -I Lif Xj! ti le
r va= 7 j
, ,�at,
::: ;
.�_ T " --ji\4 C1--:_3 t ( f L �1�' ` o -I1 I„�
fi�� n t ! Y
Total Platform area `t"t�7�'>}' ,� ;i1 v ._- c 3���� �� /U-{' 1 y
1
Groin length/lt _ ti�‘(y ,�
Bulkhead/Riprap length ` \
--- _ J
Avg distance offshore `-`•'
Breakwater/Sill
Max distance/length ---
Basin,channel -•---
Cubic yards --•---
Boat ramp -- .- + `' }
Boathouse/Boatlift,X c�l a 154- 1� -
t .
Beach Bulldozing_'"" y Ztn,
Other
"'rn�:46 r7 7f 1
SAV observed: yes ei
Moratorium: n/a yes .
Site Photos: yg�
Riparian Waiver Attached: yes 1 e5)
A building permit/zoning permit may be required by: -, t ,•
Permit Conditions $)A t(_LLJ),L `J LU , -, A ti L/.i_. f C 1 TAR/PAMINFUSE/BUFFER(circle one)
���, 1.1 pi -�+1+.'�' yn-►' _.��:�LT�L�f•�+ �L��1 Z �. L. I See note on back regarding River Basin rules
/ , 7- f i See additional notes/conditions on back
i
/ to L--i_yr: ><s� iJ E�tl:i it. �[.�\
3
i oe.,,,,,_,,,,r,
I AM AWARE OF STATUTES,CRC RULES AND CON. •NS THAT APPLY TO THIS PROJECT AND REVIEWED CO MPUA ST NT. (Please Initial) If.. i
A or Applant PRINTED Name PermilOffi r I E0 Name w
.,�1 �, ,
Fgnature•'P, ase read c• pllan element on back of permit*. Signatures --
J n
Application Fee(s) Check#/Money Order Issuing Date Expiration Date

o�0F`°"ity CAMA DREDGE & FILL I No 92538 A B KD
= GENERAL PERMIT Previous permit
Date previous permit issued
New n Modification n Complete Reissue ❑Partial Reissue
As authorized by the State of N� frthCarolina,Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
I 5A NCAC Ff r! • /01 0 0 n Rules attached. ❑ General Permit Rules available at the following link:www.dea.nc.gov/CAMArules
Applicant Name 3e. '1 D fl J Authorized Agent £,i1 01 irla (t, ij2. ) L
Addr c ", U Project Location(County): 6e0: ///1 t,�
City State &C ZIP Street dress/State Road/Lot s)
Phone#Rio) i V 1 <I A ' -1 t ?.'U •
Email Subdivisi, ��
City ' / (�
f 1X( ZIP / D(�!
+' (--
Affected I CW EW PTA ❑ES ❑PTS Adj.Wtr.Body v(J J�J�) //)//�n 'A/� (nat/man/un
AEC(s)- ❑OEA IHA UW ❑SPIMA ❑PWS Closest Maj.Wtr.Body t 1�L'L (I & aiy i
447' PNA: es no ORW J , Wv)ir'j/NQ'v1 1 Q A'1'�(`l +tj�J J�f'�'�
Type of Project/Activity)�;41141A%(Amu p kc Yfl 1 tr KyeO 1r (��u�1 `/r+t.Q- 1 A- I I
= '
)
Shoreline Length 75 ' PrZVA`a 191 rj...........\i6 ) , „„ i
Access Length t- I
Pier(dock)length z I. X ° i 1
Fixed Platform(s) . ' t 10---.--.
'' \l 7
CI")
Floating Platform(s) a t ,
Finger pier(s)3x/ 'f�j� p T'31 \ t - I ( .,f� `0
�
Total Platform area .J T' f F 3V(1g .. /1 I _ )V�/-l 1 s�/1 + ._.._. .... _-_._.
Groin length/# —' _� ,
Bulkhead/Riprap length s----- $'
€
Avg distance offshore L' 6 I-. ..._._...... t , ..._.
Breakwater/Sill ,
Max distance/length " ( t
Basin,channel
Cubic yards
Boat ramp
— a ,
Boathouse Boatlift
a ?la'x '
Beach BulldozinItPg ? '" J
Other t 1 1�. \tip,��'s( .. .JL ,
j ..... ......... r...._...._ ..... .........
1 t
SAV observed: yes . j ' i
Moratorium: n/a yes 4 I..
Site Photos:
Riparian Waiver Attached: sg, 6 ,
A building permit/zoning permit may be required by: (-) (4k) GA..
Permit Conditions 1, At( WII, �1(Lu j
IN Qie'l( yAN.(.40g5 J ❑TAR/PAM/NEUSE/BUFFER(circle one)
tf v 1 Ham,' - I4(O E-C�/j r ❑ See note on back regarding River Basin rules
4LI,v 1-I 1 d ��, i f L .anAll.e
30y� � �"`'�1 � ... ❑ See additional notes/conditions on back
I AM AWARE OF STATUTES,CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANC ST' T. (Please Initial)
Agent or Applicant PRINTED Name Permi Offi -r s•(I;,'ED Name
vr or
Signature**131pase read compliance statement on back of permit** Signature
Irip9tCQ— E(13 IQ/ 'Mg Q/` - 42-1-1
pplication Fee(s) Check#/Money Order Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application and permit conditions. Any violation of these terms may
subject the permittee to a fine or criminal or civil action; and may cause the permit to become null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for
compliance. The applicant certifies by signing this permit that: 1) prior to undertaking any activities authorized by this
permit, the applicant will confer with appropriate local authorities to confirm that this project is consistent with the
local land use plan and all local ordinances, and 2) a written statement from the adjacent riparian property owner(s)
has been obtained, or proof of delivery of certified mail notification of the adjacent riparian property owner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar- Pamlico River Basin Buffer Rules Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules
for the River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the
NC Division of Water Resources. If you have any questions, please contact the Division of Water Resources at the
Washington Regional Office (252-946-6481) or the Wilmington Regional Office (910-796-7215).
Notes/Additional Permit Conditions:
Please ensure all debris associated with the removal or construction of the permitted development is contained within the authorized
project area and disposed of in an appropriate upland location.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave Morehead City, NC 28557 943 Washington Square Mall Washington, NC 27889
252-808-2808/1-888-4RCOAST Fax:[phone] 252-946-6481
(Serves:Carteret,Craven—south of the Neuse River,Onslow Fax:[phone]
Counties) (Serves: Beaufort,Craven—north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Elizabeth City District Wilmington District
401 S.Griffin St.Ste.300 127 Cardinal Drive Ext.Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax:[phone]
(Serves: Bertie,Camden,Chowan,Currituck,Dare,Gates, Hertford, (Serves: Brunswick, New Hanover and Pender Counties)
Pasquotank and Perquimans Counties)
http://portal.ncdenr.org/web/cm/dcm-home Revised 6/01/2021

�e'CoAsr4( CAMA DREDGE & FILL No. 92538 ABCD
y =aGENERAL PERMIT
SRO Previous permit
Date previous permit issued
El New n Modification Complete Reissue III Partial Reissue
As authorized by the State of Nprth Carolina,Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
15A NCAC
I"1-4• )oZ it
III Rules attached. I I General Permit Rules available at
at the following link:www.deq.nc.gov/CAMArules
Applicant Name % Authorized Agent INCTf /�i �i(.(; F E,t
Address .— ` ( f i 1'� i Project Location(County): �1.,' ]I/,l �& i
City • ( ; ^) tate r'` . ZIP Street Address/State Roa/d/Lot ss)
Phone# I) - - i ji (U'1 L'1'(7L(,) J) /1
Email — Subdivision J
City %) )Pilrb 1 ZIP � fir (1'
Affected n CW EW t PTA n ES n PTS Adj.Wtr.Body y`I 1 W / (nat/man/unk)
AEC(s): n OEA n IHA n UW ❑SPIMA ❑PWS Closest Maj.Wtr.Body 141/�( NUCU(W &Wit.)
ORW:yes/no PNA:yes/no J
c_oleir 1,30 a a ilietri
Type of Project/Activity , ,n► /.Ky) ,
�1 — (lilt: (Scale:! I0
Shoreline Length Zw �J mstemas.sison ,n
Access Length
t 4
Pier(dock)length / EMS *'
Fixed Platform(s) (p)<riC " ' t 4 XI�L �I- ��'� . .a-- _ Ill
Floating Platform(s) -- ! ry * i . '
pt� y! i ,,,,\,i; .
Finger piers)3XI j`T �1�7u` I ),� I . ; 1 c 0
Total Platform area \*)‘ )
a i
Groin length/# c i i
-11
Bulkhead/Riprap length 'l� —`
Avg distance offshore
f 1
Breakwater/Sill •
Max distance/length
Basin,channel , 1 '
Cubic yards I .
—�_
,am
Boat ramp Q t] L' ) ,
l Boathouse/Boatlift 1�/ )J a r
Beach Bulldozing � , y
,�^' 4
Other N{ v'�t ___._.__._... -
f r..
SAV observed: yes 4no) i i
i
Moratorium: n/a yes no i
Site Photos: no! " I - .r
Riparian Waiver Attached: yes �f i ,
A building permit/zoning permit may be requiredrequired by: ' lit.A 6 KA
J t ` 1 AJ( ` j_i � it O Q-V ^ ^�� �� G f^S6 ! n TAR/PAM/NEUSE/BUFFER(circle one)
k.
Permit Conditions � J .Y -may` ///��� w
► i Ul r 1 a l c/� �(� � �,�. U �{�(%�f �� f7/ �- n Seenoteon backregarding RiverBasin rules
2_44Yf • D J4 I ttttfi % ' (, '( /(i mai0�.07iu'
�p ,�'! � n 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
Application Fee(s) Check#/Money Order Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application and permit conditions. Any violation of these terms may
subject the permittee to a fine or criminal or civil action; and may cause the permit to become null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for
compliance. The applicant certifies by signing this permit that: 1) prior to undertaking any activities authorized by this
permit, the applicant will confer with appropriate local authorities to confirm that this project is consistent with the
local land use plan and all local ordinances, and 2) a written statement from the adjacent riparian property owner(s)
has been obtained, or proof of delivery of certified mail notification of the adjacent riparian property owner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar - Pamlico River Basin Buffer Rules Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules
for the River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the
NC Division of Water Resources. If you have any questions, please contact the Division of Water Resources at the
Washington Regional Office (252-946-6481) or the Wilmington Regional Office (910-796-7215).
Notes/Additional Permit Conditions:
Please ensure all debris associated with the removal or construction of the permitted development is contained within the authorized
project area and disposed of in an appropriate upland location.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave Morehead City, NC 28557 943 Washington Square Mall Washington, NC 27889
252-808-2808/1-888-4RCOAST Fax: [phone] 252-946-6481
(Serves:Carteret,Craven—south of the Neuse River, Onslow Fax: [phone]
Counties) (Serves: Beaufort,Craven—north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. Ste. 300 127 Cardinal Drive Ext. Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
(Serves: Bertie, Camden,Chowan, Currituck, Dare, Gates, Hertford, (Serves: Brunswick, New Hanover and Pender Counties)
Pasquotank and Perquimans Counties)
http://portal.ncdenr.org/web/cm/dcm-home Revised 6/01/2021

ilio""14tet,11CAMA I I DREDGE & FILL No. 92538 ABCD
1 GENERAL PERMIT Previous permit
Date previous permit issued '
n New n Modification n Complete Reissue n 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 5A NCAC Rules attached. ❑ General Permit Rules available at the following link:www.deq.nc.gov/CAMArules
Applicant Name Authorized Agent 1�
Address Project Location(County):
City ( State ZIP Street Address/State Road/Lot#(s)
Phone#( ) ' —1 `cf
Email Subdivision
City ZIP
'� r
Affected n -` .cw -EW I PTA I I ES ❑PTS Adj.Wtr.Body _ t (nat/man/unk)
AEC(s): l I OEA f I IHA n UW n f 1 SPIMA ❑PWS Closest Maj.Wtr.Body -1-c 14,41(. : y ): ,.I
ORW:"yes/no PNA:yes/no
13 ) %-i iLi ww 1,4.
Type of Project/Activity ,1 .K .�
1 ,1!P- 4 02-f.Ulikt1iJLC.., ,i—fbit L�" i
Shoreline Length 75 .,At� --.•-,..�-1 r N...T....= 1' F ! j
Access Length , ( ( — ........ . ..... ... _._..__.,
Pier(dock)length LC-',X 1 q r -' 1
Fixed Platform(s) i�><,�G y I LI Xlq .:. *4)
/ ° "
Floating Platform(s) .....\
+ ' _ p py g }
1 1r
Finger pier(s) �//�, 3� , uC� , / ^ Vv
L � ��tt�� LJ t
Total Platform area `�—I() lc-~ S,✓ 1 ,r-... I
'� I
Groin length/# i.IT
; j
Bulkhead/Riprap length
Avg distance offshore — ; ..... .. ...._.._.-)-_ -._........ _ -........... ......._.__....
Breakwater/Sill I t
Max distance/length I 1 '
` j - " . i ,
Basin,channel
Cubic yards I ) E
Boat ramp i z _... .._.._._�1 --___
� le)'u►r)' ,Boathouse/Boatlift { �
Beach Bulldozing H �� 4
Other . t,4 ;*?Y�t 0 .j. !
+ ± i
f SAV observed: yes no _j
Moratorium: n/a yes i'no I " . } ' I w ^
Site Photos: yes no i " I . 1
Riparian Waiver Attached: es no I i
A building permit/zoning permit may be required by: r ' :iL.iv,'t ti
Permit Conditions ( I ❑TAR/PAM/NEUSE/BUFFER(circle one)
\ , j id.titeitr 1 " t- L' I(-j ) r i See note on back regarding River Basin rules
It ( 1 l j ti I r((// `l III(ity 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
Application Fee(s) Check#/Money Order Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application and permit conditions. Any violation of these terms may
subject the permittee to a fine or criminal or civil action; and may cause the permit to become null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for
compliance. The applicant certifies by signing this permit that: 1) prior to undertaking any activities authorized by this
permit, the applicant will confer with appropriate local authorities to confirm that this project is consistent with the
local land use plan and all local ordinances, and 2) a written statement from the adjacent riparian property owner(s)
has been obtained, or proof of delivery of certified mail notification of the adjacent riparian property owner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar- Pamlico River Basin Buffer Rules Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules
for the River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the
NC Division of Water Resources. If you have any questions, please contact the Division of Water Resources at the
Washington Regional Office (252-946-6481) or the Wilmington Regional Office (910-796-7215).
Notes/Additional Permit Conditions:
Please ensure all debris associated with the removal or construction of the permitted development is contained within the authorized
project area and disposed of in an appropriate upland location.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave Morehead City, NC 28557 943 Washington Square Mall Washington, NC 27889
252-808-2808/1-888-4RCOAST Fax:[phone] 252-946-6481
(Serves:Carteret,Craven—south of the Neuse River,Onslow Fax: [phone]
Counties) (Serves: Beaufort,Craven—north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Elizabeth City District Wilmington District
401 S.Griffin St.Ste. 300 127 Cardinal Drive Ext.Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax:[phone]
(Serves: Bertie,Camden,Chowan,Currituck, Dare,Gates, Hertford, (Serves: Brunswick, New Hanover and Pender Counties)
Pasquotank and Perquimans Counties)
http://portal.ncdenr.org/web/cm/dcm-home Revised 6/01/2021

Styron, Heather M.
From: Sherry Tipton <[e-mail]>
Sent: Friday, October 20, 2023 11:12 AM
To: Styron, Heather M.; Sherry Tipton
Subject: [External] 309 Grand View Drive
Attachments: Joe Martin CAMA Docs.pdf
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Hi,
We should be able to permit it by next week?
Thanks
Parris
Have A Great Weekend,
1

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
r
Name of Property Owner Requesting Permit: . :VD CO iv ja r i- n
Mailing Address: MYq Grmyt iiiuj Drl y '
3V)ea15 rrti N c
Phone Number: 11 - tA d
Email Address:
I certify that I have authorized Vl i1�TT Mee ri l Coil' C --j ol� LC.L ,
Agent/Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits ff''
necessary for the following proposed development: SIX(5 rp/erg aei)'461
a nrp ier ; l4-5(I ' RQa ' f 5 1e(1ni ,5-Arkon
at my property located at ogn 6T 1) '¢-eW Dr/ lie 5/)ea--/j Fe;rry
1
in 01161b 00 County.
I 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:
i Signet eg
Joseph 1�f .rTh'h
Print or Type Name
CLvtve
Title
/0 l $ l '
Date
This certification is valid through / /

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If YES,enter delivery address below: 0 No
Ms. 4 r9 8 1i h let rn5
( 54 pis ne &roe Drive
Pcilm C,oc(6-1-1 F(aVridi 69.101
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PS Form 3811,July 2020 PSN 7630-02-000-9053 Domestic Return Receipt
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N.C. DIVISION OF COASTAL, MANAGEMENT
. • ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAID • RETURN RECEIPT REQUESTED or HANG? pEl_�,VERY
(Top portion to be completed byowner or their agent)
Name of Property Owner:._.__.JL15J2f2�I 'LQLT/{. 0 --
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Address of Property: . 01 I-(tryl vi(_L.k.) Dri v'e ._)/1eCjc_ T I d_j! c AP-(')
Mailing Address of Owner:__ ��, L _--__ J
Owner's email; __.._. ��,Owner's Phone#: _ 1/O~_ 4 /. /�/1 �,f
Agent's Name: ;7 j .±jh 0. .L.f..a,/,
LL]Liji.,11M Agent Phone#: grit) "t . ' ..L.701./7
Agent's Email: F.:A/Lethricinnex.eyuirte<- L.Of) _1" *teal 14 (.0 _
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
43ottotnportion tp be cQmaleted.bv the Adjacent Property Owner)
1 I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
,A-t a 1 permit has described to me, as shown on the attached drawing, the development they are proposing. A
doscriptien car drawing with dimensiog, mugt beprovic1ed with this letter.
fr
} ;� , ,_ I DO NOT have objections to this proposal. _ _ I DO have objections to this proposal,
li you have ob/fictions to what is boing proposed, you must ii-as fir ii I fiii—N-TC Division of-Coastai
Management (DCM) In writing within 10 days of receipt of this notice, Correspondence should be
mailed to 400 Commerce Ave.,Morehead City, NC 28557. DCM representatives can also be contacted
at(252) 808.2808, No response is considered the same as no objection if you have been notified by
Certified Mall.
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
11 (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 /, /f
Siure of Adjacent Piparian Pia gnat arty Owner
-OR..
I do not wish to waive the 15' setback requirement (initial the blank) _
J A / /
Signature of Adjacent Riparian Property Owner: < ..4 '__ ;(i,• ,__ _
Typed/Printed name of ARPO: if 4/ f() re (_I
. Mailing Address of ARPO: ,� �� i,C .,, i'c ,r � ,S c C�
0 ARPO's email: _ _ ARPO's Ptione#:
Date: , /C & --> 1 j _*waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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October 23, 2023 e6
1:500
Lil ()Iv, 0 0.004 0.008 0.016 mi
0 0.005 0.01 0.02 km
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