87247A - Bosomworth, Phyliss

�°00M)"& CAMA ❑ DREDGE & FILL N9 87247 A B C D
Previa 41 GENERAL PERMIT Date Devioupermit
Date previous permit issued
New [-]Modification ❑ Complete Reissue ❑ Partial Reissue OR
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/CAMArules
Applicant Name
Address
City
Phone # ( )
Email
State ZIP
Authorized Agent I. , !
Project Location (County): --
Street Address/State Road/Lot #(s)�''
Subdivision
City
Affected ❑CW ❑EW ❑PTA ❑ES ❑PTS Adj. Wtr. Body ---... i-. x F,y-rf--'(dat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/riot PNA: yes/no
Type of Project/ Activity � -
(Scale:F., Y. )
'
I
'
Access Leng[hT
r
Pier (dock) length�—
_
r
Fixed Platform(s)
T
Floating Platform(s)
-
-fi
Finger pier(s) I
:_
9
.o..c
-
t__'.
,�t>t
_
Total Platform area
I.
Groin length/#
Bulkhead Ri length
!
�}
-ff.
C
}
'Y
J
'1
-
-�-
a
j
ra
Avg distance offshore
/7-.
�>•'3t
JCS
12f
J
fU
Breakwater/Sill
Max distance/length
Basin, channel<
'r'-'
LE
—I
`.rye
f
j
Cubic yards
Boat ramp
�
(--
Boathouse/ Boatlift
Beach Bulldozing'
-
Other
_
SAVa: yes
-
Moratorium:orium:• n/a ' yes no
Moratorium:
'
Site Photos: yes no
�'
Riparian Waiver Attached: yes no
A building permit/zoning permit may be required by: v o � n v (111.1. .�
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 Initial)'
Agent or Applicant PRINTED Name I IPermit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit" Signature
Application Feels)
Check N/Money Order Issuing Date
Date
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RECEIVED
&C. DIVISION OF COASTAL MANAGEMENT 1 2024
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONFlNAIVER FORM
CERTIFIED MAIL RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be
completed by owner or their agent) DIcM-EC
Name of Property Owner \ � 00,0 TvW _ o v 4,
Address of Property_ �� R e cw0
Mairmg Address of Owner
1L �5Z 33� Slsl
Owners email.— � 115 Jn.. 1 1R� I Prn d Kl)-d Owner's Phoned:
Agents Name_ �AridehLv rleje ZIC. Agent Phone#;k53--33r-
Agents Email_
:n
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATIOii
(Bottom portion to he completed by the Adjacent Property owner)
I hereby certify that 1 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
✓ I DO NOT have objections to this proposal- i DO have objections to this proposal.
If you have objections do r®rft. is being proposed, you must notify me N C. Division of Coastal
1lfanagement (DGAI) fn writing wfthln 90 days of receipt of Phis notice Correspondence should be
mailed to 40f £ Griffin Si, Ste 200, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at (252) 2&4_Ml. A% response is carasfdered the same as no objcc90 iFyors have been
notified by Certified AWL
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minenum distance of 16 from my area of riparian access unless waived by me
(this does not apply to bulkheads or ripmp revetments)- (If You wish to waive the setback, you rzust sign
the appropriate blank below.)
I DO wish to waive sometall of the 15' setbac
Signature of Adjacent Rlpana. Pmper[y 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 AR
Mailing Address of ARPO:
ARPO's email:
Date:
ARPO's Phonet":
*waiver is valid for up to one year from ARPO's Signature"
Revised July 2021

RECEIVE[
-I.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAPJER FOR R _ 1 7.624
Name of Property
Address of PropeM
Mai" Address of
Owners email e s Phone#
Agents Name: LQl r 1n 2 p 7n. c Agent Phone# S a^ I
(Top portion to be completed by owner or their agent) D C M ®E C
i�
Agents Email:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(i3ottom portion fa ire compteted 6v the Adiacent Proggrk Owner)
I hereby certify that 1 own property adjacentto 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 obiec5orrs to this proposal- I DO have objections to this proposal.
If you have objections to what is being proposed; you must notify fbe 1V.C. Division of Coastal
1Jlanagement (DCkV fn wrMg wftfurr 90 days of receipt of Siis noffce- Correspondence should be
mailed to 9F11 S. Griffin St, Ste 300, Eiizabefh City, NC, 27909. DCM representatives can also be
contacted at (252) 2643901_ NO response Is rxrtasfdaye f the same as no objection rryou have been
notified by CerMed rlfaff.
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 IV 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-)
1 DO wish to waive some/all of the 15' setbac3' L A� �/
Signafure of Adjacent Ripanan Properly 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:
Mailing Address of ARPO:
ARPO's email:
Date:
ARPO's Phone#:
*waiver is valid for up to one yearfrom ARPO's Signature"
Revised July 2021

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