87241A - Midkiff, James and Lisa

LJI.Jo►MA �J LlIREDGE & FILL LV O/GItl A B C D
GENERAL PERMIT Previous permit
Date previous permit issued
EnNew ❑ 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: www.deq.nc.goy/CAMArujas
Applicant Names s i kt F Authorized Agent p,., t
Address - I Project Location (County):
City State - ZIP i ?. ) Street Address/State Road/Lot #(s)
Phone # O
Email - Subdivision
City ZIP
Affected ❑ CW M. EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body - (nat/inan/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
Shoreline Length
Access Length
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger piers)
Total Platform area
Groin length/q
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/Sill
Max distance/ length
Basin, channel
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
SAV observed: yes no
Moratorium:, n/a yes no
Site Photos: yes no
Riparian Waiver Attached: yes no
A building permit/zoning permit may be required by:
Permit Conditions
(Scale: )
❑ 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
Application Feels) Check#/Money Order Issuing Date
Expiration Date

Name of Property Owner Requesting Permit: �e/ft � 3144�01 M
Mailing Address:�O
�� a33aa
Phone Number:
Email Address: �qn��, d {,�,tom
I certify that I have authorized
U Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA perm As
necessary for the following proposed development: Jry4o Q dO8 LF
VMR 6 (ru.QCltda L d mrliA&
at
in
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:
-firllfl .
Title
p�
This certification is valid through " i / I / J4

N.C. OF COASTAL MANAGEENT
ON
ADJACENT RIPARIAN PROPERTY ROWNER ONER NOTIFICATIONNIAIVER FORM
=1Ei.laS2_k'1`f31K'E3I9._fiF..CxI'S..E3�41USI
(TOP rPortion to be completed by owner or their agent)
Nairr" Properly Owner. \r�i
Addressor Property:r-,)-7174 4
Mamrtg Address of owner r , r . , ti� >Pjat flAt _ Via 0 33ca-d
Owneesemali!l1ty;.y,(yU,�}ti/ �j �j tam CwneesPhono*
Agent's Name ((torn"` 7rtt ot✓!/) 1 4b .
Agent's Emali, c4rirnefc b fib c , (c; r,
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(091110M tortion to be cad by She AdlacepLProoerh Ownen
1 hereby certify that t pure pro, arty hd,,ac:nnt to th®nonvr e'ornnu d p•ageny. The motvidual apply V for this
ltcnnt has descrbed to me, as shown on tho anachec drawing, the devuloMent they are proposing. A
c-i��tpD..Q�.r1'KwLR4�w�h. Im r � ^ ..fTL4i3.4a�P�dedw h 'oge(.
100 NOT have objections to this profwset. 100 have oNections to this pmposat.
d you tmve ob/act/dns to what is being prnpased, you must notlty the N.C. Division of Coaster
Aljnagement (DC" In writing wirtrin 10 days of receipt of this notice. Corrospondence should be
maiMd to 401 S. Griffin St, Ste. 300, ENzahetti City. NC, 27909. DCM roprosentativas can also be
con&mted at [phone]. No response 1s considered the san ii as no objection If you have bean
nOWW by Certified Mall.
WAIVER SECTION
1 underVand that any proposed pW, dock, mooring pilings, twat romp, bfeakwatar, b r afhouse. Rh, or
groin must be set back a minimum distance of 15' from my area of dpanan access unless waived by me
phis does not apply to bulkheads or npfap rovotmantS). (If you w`ah to waive the setback, you n1ug Mon
the appropriate bunk below.)
I DO wish to we" somelall of the 15'setback af,•' 4 1r
Sipnetrre orAQlacanr � ftioarty outer
_OR.
I do not wish to wahro the 15' setback requirement priltial the bank)
� SIgnature of Adjacent Rlpartan Property Owner
Typed/Printed name of ARPO:
► cuing Address of ARPO:
ARPO's emeli:
ARPO's Phones:
Dante: :2—Aq— ;;L7 "watwr Is valid for up to one yta(trom ARPO's Signature•
Revised Jury 2021

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,
Address of Property: _
Mailing Address of Owner.
Owner's email:
Agerrt's Name: (GtLn�u�c
Agent Phone#: aV - 3)) - 14IL44
Agent'sEmall:�y{�.1_()u?ac (Uil��_ Frig z�,IrYln�v CG%Y1
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(bottom portion to be completed by the Adlacent Property Owner)
i hereby certify that I own property adjacent to the above referenced property. The IndWual applying for this
pemM has described to me, as shown on the attached drawing, the development they are proposing.
I DO V1 T hs ve objections to this proposal.. I DO have objections to this proposal.
u you nave objections to what is Being jroposed, you must notify the N.C. Division of Coastal
Alanagement (DC" in writing within 10 days of receipt o1 this notice. Correspondence should be
malted to 401 S. GHMn St, Ste. 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at [phone], No response /s considered the same as no objection /f you have been
nofi'fieed by CertMed 114all,
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, it, 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 riprep revetments). (If you wish to waive the setback, you must Sion
the appropriate blank below.)
I DO wish to waive some/all of the 15' setbpT�; ° �/j
PL�U_
Signature of Adjacent Riparian Rvperfy Owner
I do not wish to waive the 15' setback requirement Qnhial the blank)
'Signature of Adjacent Riparian Property Owner ,LIU (66ty4?(`bhp,
Typed/Printed name of ARPO:lrrllI
Mailing Address ofARPO:�w�.IU
ARPO'a emailr`'p "Pas Phone#: "0 i
"waiver Is valid for up to one year from ARPO's Signature"
Revised July 2021

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