87227A - Jagucki, Ted

ACOMF° ❑CAMA ❑ DREDGE & FILL N9 87227 A B C D
GENERAL PERMIT Previous permit
Date previous permit issued
E! 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
15A NCAC a (� I f•' ��' []Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name
-[ i"_A .J Q t
Authorized Agent .)'Am'r
1 V i J WL l'{
Address
f-J f) e) O Y_ 2. ( 1
Project Location (County):
C 'rY 1 } V C
City Cv f (1 ln.6'l State h� C_ ZIP Y,. 7 `. � .'+ `)
Street Address/State Road/Lot #(s) ) O : "�
Phone # aL,5L2-)
(nt ( �! ' ((�, in
L_ 0.1A e,
Email t- 1_ 1� 10-9
((
U C Ql wci 1 • C6yy 11
Subdivision W nA1
t 7.. r-. I Cl Y\
v% U A
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City �_�'A rR_rs CSJ
ZIP 2,
Affected ❑CW
v
❑EW ❑PTA OES ❑�PTS
Ad' Wtr. Body C C1 yt "-�
I• Y
, t P -00 W C.(ti 5 �> CJ. (namaay�unk)
AEC(s): ❑ OEA
❑ IHA ❑ UW ❑ SPIMA ❑ PW5
Closest Maj. Wtr. Body
i�
�. U Y Y 1 IC UL C. f� (t ^.. Cit
..
)
ORW:yesy,,.N/
1
PNA: yes/pg./
Type of Project/ Activity 1.< t C L c F ( CI, o' b t, ( (C k C n A .
(Scale:1 _ w)
Shoreline Length "f O
Access Length
—I
I-
-
-
--
-
-
-
--
-
--
-
-
-
-
Pier(dock)length
--
-
Fixed Platform(s)
i
Floating Platform(s)
Finger piers)
_
T-
i
T
-
_
{•)
_
)
_
_
51
Total Platform area
v
Groin len gthN /
_
-�-
I
_ _�--._
-
-..._.
_
I
I
Bulkhead Rira len h
_..... P P gt
Av distance offshore
g
--
i
Breakwater/Sill
I
i
Max distance/length' '�
--"
"-
-
--
--
I
Basin, channel i
Cubic yards
Boat ramp
Boathouse/ Boatlift
FF
(
o tk
(
c {
rt
-
Beach Bulldozing
Other
�
-
_
SAV observed: yes no
'
YN
Moratorium: (n/a yes no
Site Photos: yes no
-
~
-
-
RiparianWalverAttached: yes no
..._
i...
..
__.._.
.._
A building permit/zoning permit may be required by: C: LAk' I I'�'UtC" " i- J
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, GRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWEO COMPLIANCE STATEMENT. (Please Initial)
Agent or Applicant PRINTED Name
Permit Officer's PRINTED Name
Signature "Please read compliance statement on backof permit•• Signature '
Application Fee(s) Check k/Money Order Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: I—ed ZT4 A ( k 1.
Mailing Address: -() - 80Y, a 17
(3CQodyj Ai P s2-79.Z,9
Phone Number: 42-5a — 6 1 q i j Le j a
Email Address: . 9 jr • to 'I c orn
I certify that I have authorized %" t Bfll S r0n 4
Agent r Contractor /
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
its l a 6-luxiaige
at my property located at 109 JC:W -
in 0,(1YrfiU(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 InfontAon:
/ Signidurb
d torTypeN e
Tifle
Date
This certification is valid through _�

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERT)FIED MAIL RETURN RECEIPT REQUESTED or HAND DE �tiFRV
(Top portion to be completed by owner or their agent)
Name of Property Owner. A
M alC4ck r 1 e t /` r�
Address of Property: I (A 300 k nC-6AA�( 1 i ,2 -79. 7%
Mailing Address of Owner. �� X n277 t„'r(' (,( A O %Q
Owners email: ,C(M Owner's Phone#:r.(�/a�[�.,-,n
Agent's Name: Agent Phone#: E9:L2 j1"'Ic rf 7
Agent's Email:
RIPARIAN PROPERTY OWNER'S
I hereby certify that I own property,edjacentio the above referenced property. The individual applying for this
permit has described to me, as shown on the-attashedtdrawing, the developmen they are proposing. A
kvilp—gon or drawing with dimensions, must bg Provided with this letter t rG
hDO NOT have objections to this proposal- __ I DO have objections to this proposal.
h
A u you nave Mections to what is being proposed, you must notify the N.C. Division of Coastal
C- ( Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
(jr riled to 401 S. Griffin St, Ste. 300, Elizabeth -City, NC, 271)09. DCM representatives can also be
contacted at(252)264-3101. No responses considered the same as no objection ifyou have been
notffed byCar i red
�hEel u'
y rel
�a
qcc ..late°
Y)oe',
WAIVER SECTION (Choose only...
understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, fidt, or
min must beset back a minimum distance of 15' from my area of riparian access unless waived by me
:his does not apply to bulkh ds or rirevetments you wish to waive the setback, you mus si n
1e aoorooriate blank balm I -
100 wish to waive some/all of the 15'
.OR_
DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Prypytty Otyner; ff (/, I ✓ t
TypedlPrinted name OfARP jYli jpS
Mailing Address of ARPO: 7 q 14(irft({ f'tL-1 -1J_i ia) �h g30
ARPO's a ii: {1'{7/jr/S kJ ` ARPO's Phone#:
Date: 7 aiver is valid for up to one year from ARPO's Signature*
in S�Q('ItJ �e R vised August 2022
a
u/

N.C. DIVISION OF COASTAL MANAGEMENT
ZECEIVED
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property owner:
4ddress of Property:
Mailing Address of Owns
FEB 2 6 2024
DCM-EC
f: P6.
r" N� 1 1
r ' ;-LFI�NO to
Owner's email:�ra. n � — "u� rcm
Owner's Phonek
v �i
Agent's Name:Mr`o rKl Agent PhonefR:a2�2-c5gri "�
Agent's Email: IU i
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adlacent Property Owner)
1 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
...
S X I•DO NOT have objections to this proposal. I DO have objections to this proposal.
n
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 (Choose only one
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 riorao 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
fgnature 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: 4&--/1°`/ 1
Typed/Printed name of ARPO: U (Y)^j Lnloies`�Y it i rn
Mailing Address of ARPO:
ARPO's email: l Pf-J4f)T1*tll%-®C.eA2-J 6gARPO's Phone#: _ v
Date: 2910 •waiver is valid for up to one year from ARPO's Signature*
111 5e o— b-5-(' Revised August 2022

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