87288A - Rose, Ron and Lisa

tA°tcofiaztt OLAMA ❑ DREDGE & FILL N9 87288 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:
15A NCAC ❑ Rules attached. eGeneral Permit Rules available at the following link: www.deq.nagov/CAMArules
Applicant Name Authorized Agent N: / e."
r II
Address Project Location (County): (' 4 t
City C k i State ZIP Street Address/State Road/Lot#(s) Yrs
Phone #(7•-,:.)
Email Y n t
Subdivision
City l _ lL t' t ; A,.s A' ZIP 1 "7 ') I Ci
Affected ❑CW ❑EW ❑PTA ❑ES ❑pTS Adj. Wtr. Body OotA, k J:I` -, (tnat(man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body I a r Ir l - r- n Lt Ix r i
ORW: yes/no PNA: yes/no
Type of Project/ Activity ,-r r O VJ 1 t �L i
(Scale:1 a 10 )
Shoreline Lengdh
Access Length
le
■0
■
■
pp
■
No
■N
i
�
■Gi:�:
I
:::
Floating Platform(s)
Finger pler(s)
�::■C:.■....
Groin length/#
Bulkhead/ Riprap length
Avg distance offshore
Max distance/ length
Basin, channel
yards
Beach Bulldozing
Other
■■..■..
�..
■
■.:...■■■■■
:�:
::
�:
■■�
■■N
�.i�■■■■■Cubic
No':::
..:
.l.
■■■�■■'
IN
0
0
pi
ME
.■
.
.
■...:■■,
■
MEE
PAN
SAV observed: yes
Moratorium: po yes no
Site Photos: C%S> no
Riparian Waiver Attad I
oil
R2�
■
���,
A building permit/zoning permit may be required by:
Permit
❑ TARIPAM/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••
Application Feels) Check #/Money Order
Signature
Issuing Date + .I Expiration Date

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONlWAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or NAND DELIVERED
i o-
Name of Property Owner: p► ©3 h "* L_% S N r \ a 5Q , t //t
Address of Property 6 D Ra �iY� �D 4w eµfT,10— 1�+� `�� ° `G�
(Lot or Street #, Street or Road, City & County) r
Agent's Name #:
Agent's phone #:
Mailing Address:
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.
1r I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the 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 (252) 264-
3901. No response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a 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. (If you wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
ro erty/Cr*ner Information)
(Adjacent Property Owner Information)
I 1
01/
� t//
Signature
Signatu` * U
�V {� S� e
/ l
ii
� t( t.L�t G��
PrintorType
Print or Type Name
��Name
!4 ®lam V" f
—\->C 7?sL'iy
Mailing Addresss.
Mailing Address
`
IlVtr Z`"��
Citylstatelzip n
City/State ip
/
2-S2 333--5by®/MA1-ose 0y A.com
D�4S9 R� �
Telephone Number Efriall Address
Telephone Number/Email Address
ZI is /2D2,3
Date
Date*
'Valid for one calendar year after signature"
Revised Jan. 2017

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the tack of the maiipiece,
or on the front if space permits.
1. Article Addressed to:
SC aT+ 4 11 r1n via m W rmI
i'fd tptJtuwt �F l
Cus+i d��u, N i.�9 a9
(IIII(IIIIIIIIIIIII IIIiIIIIIIIIIIIIIIIIIIIIIII
9590 9402 7485 2055 2033 79
2. Article Number frranafor from service labe0
PS Form 3811., July 2020 PSN 7530A2-000.9053
F
D. is
It
❑ Agent
4 Addressee
'nt ) C. Date of Delivery
eYfromtm17Ym ❑ e
letivery e0rew below. ❑ No
312SI23 1:2-1 Pt"l-
3. Service Type
❑ Priority Mail Express®
O AdWt S alure
O Adult Signature RSSWed Deflvery
b Certlr Mm19
OAeegg tbtareEM Restricted
Delivory
❑ WNW Mail Aastriotad Derrvery
❑ Signature ConMnetlonTM
❑ CAl1aGt on Delivery
❑ SlgrWura Confimallon
❑ 0011 ct on Delivery Rests l canvmy
R"Mctw Delivery
❑ Insured Mell
ht InWn_K Mao Reshwed Dewery
Domestic Return Receipt ,
0ri MaycV\ 2� 1 ZO-4f
*Urlt l

fi
d�;ry
1 �+
ON