87124A - Sprysenski, Martin

❑CAMA ❑ DREDGE & FILL N9 87124 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. [7] General Permit Rules available at the following link: www.dea.nc.gov/CAMAruIes
Applicant Name
City State ZIP
Phone # ( )
Email
Affected ❑ CW ❑ EW ❑ PTA
AEC(s): ❑ OEA ❑ IHA ❑ UW
ORW: yes/no PNA: yes/no
Type of Project/ Activity
❑ 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:$ pT , )
o...
Access Length
-
�
7
Pier (dock) length
Fixed Platform(s) —
--
I
-
I
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—
Floating Platforms)
li
Finger pier(s)
1
Total Platform areaALI
Groin length/#--
Bulkhead/Riprap length,-
1
Avg distance offshore-
Breakwater/Sill
Max distance/ length
Basin, channel
t
Cubic yards
y�
Boat ramp
Boathouse/ Boatlift'
i
Beach Bulldozing-
Other
_L
SAV observed: yes
�
Moratorium: nLa% yes no
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,—
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-
—
--1--
—
—
—
Site Photos: es no
—
- --
I--
-
—
RioarianWaiverAttached: yes
-
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
Agent or Applicant PRINTED Name
Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit'*
Application Feels) Check #/Money Order
Signature
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: tti • 7 Z Its Ca
Address of Property: 1 j � Yu Kt
Mailing Address of Owner:
Owner's email:
Agent's Name:
Agent's Email:
Owner's Phone#:
Agent
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
description or drawing with dimensions must be provided with this letter.
x_ 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 coasrai
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
1 understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of 16 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 c ty Owner
M
I do not wish to waive
■ Complete items 1, 2, and 3.
A Sigr
■ Print your name and address on the reverse
x
Signature of Adjacent F
so that we can return the card to you.
a
■ Attach this card to the back of the mailpiece,
,
Typed/Printed name c
or on the front if space permits.
1. Article PIdddre^ss}d to:
D. Is of
if
Mailing Address Al
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❑ collect
2.An 7020 1810 0000 7679
753%
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PS Form 3811, July 2015 PSN 7530-02.000-9053
Agent
Date of
:ry address different from item 1? ❑ Yes
enter delivery address below: @ ND
Mail Restricted Delivery
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Nary Restricted Delivery
Noted Delivery
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❑ Registered Mail*"
❑ Registered Mali Restrioted
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Returnery Receipt for
Merchandise
❑Signature CongrmatlonT"'
❑ Signature Confirmation
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Domestic Return Receipt
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