87292A - Blaisdell, John and Kathleen

❑CAMA ❑ DREDGE & FILL N® 87292 A. B C D
Previous permit
3 GENERAL 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 A )l , l i C.' L.t ❑ Rules attached. 'y❑' General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name
c, r S CU
Address
City -
state `
ZIP
Phone # (_)
Email
Affected ❑ CW
❑ EW ❑ PTA
❑ ES ❑ PTS
AEC(s): ❑OEA
❑IHA ❑UW
SPIMA ❑PWS
ORW: yes/no �
PNA: yes/no
Type of Project/ Activity _
Shoreline Length
Access Length
Pier (dock) length
Fixed Platform(s) i
Floating Plattorm(s)
Finger
Total Platform area
Groin length/ri
Bulkhead/ Riprap length
Avg distance offshore nv
Breakwater/Sill
Max distance/.length
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift /
Beach Bulldozing
Other
SAV observed: yes no
Moratorium: n/a yes no
Site Photos: yes na
Riparian Waiver Attached: yes
A building permit/zoning permit may be required by:
Permit Conditions
Authorized Agent i \ (. r(-
Project Location (County): L„
Street Address/State Road/Lot #(s) D IF. % r t• t
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❑ 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.
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
�f
Signature *"Please read compliance statement on back of permit"" Signature
Application Feels) Ofjvqjo�Wo( o: ..Y.MX Check Money Order Issuing Date
CkS+ae)t+'�I,9�a36A, ats3aa1A)--.-*usyaa7+ A)
(Please Initial) �e'
Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: l clgt / W . P!✓1�—
Mailing Address: Zo W c�uan
� t7�rv°�,✓ � nl c� z� 9 3 �
Phone Number: (.>i6
Email Address: IQcjrdcfrI ,cv.,.�
I certify that I have authorized L l «Y fo,Y) ---,J cr»✓r: T70.� L c�
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: h 41>r>1 n cl:✓
at my property located at ZO (t, burjr ,uc-- z7932—
in 04"-)A vJ County.
1 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:
Print or Type Name
Title
/O / ZA
Date
This certification is valid through

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: ; ,6 ue i l�" )s
Address of Property: Z rD In bU D 2 L=bG� ICJ 1J . AJ (Z- Z-7 9 3 Z
Mailing Address of Owner:
ff ZO(O 001jDcL -P2- /J L Z7 9 3 Z—
Owner'semail:Owner's Phone#: (v7N�-S�9S�-�460
Agent's Name: L l LL f A Nn S O•y Co s. 77,9 1 Agent Phone#: Z rL' 3 3 7 SJ yi
Agent's Email: I l 1 I,S4 ctylcjS'o.J(yJ sKt V—t7v-,/llc 0- R ✓Mcg l ( . L+17✓i`�
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.
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 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
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 riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.) n
I DO wish to waive some/all of the 15' setback // n/ / il/ / i
Signgt"ure of Adjacent Riparian Property Owner
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner
Typed/Printed name of ARPO: AARd , )oa_/ ax r
Mailing Address of ARPO: �i v.r�1pp '✓2 T de, f�J� Al4- 2 2tiL,:'
ARPO's email: ARPO's Phone#: 2S72_-?V -
Date:%/T� *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

L
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: .)s G iq ^)
Address of Property: ZCi (P � �2� �� li 1�Lnl'i7Jni fV 27 Z
Mailing Address of Owner: ((o T) V nl'��� `�/L L>C N Z 9 3 L
Owner's email zi C,e LW � 0M'1 i rlds Prrna,Ownees Phone#: L, i 6 - �5-9�; " jC>6 v
C 01K
Agent's Name: L) 40,- /a r..;5 S-.0 Cv, +;"rtJc,n Agent Phone#:
Agent's Email:LJ
�� r 2,l fOSICU J;ttTt ,J��C 4} ✓v cal I . Co•,,
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.
N 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. urvrsron or coasrar
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
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 riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.) /J
I DO wish to waive some/all of the 15' setbackL�
Signature of Adjacent Riparian Pro e y Owner
-O R-
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: rV t) 6 eVV-vIG1 r L- V r
ARPO'semail: 4' f2��iU11A ItO�AFFPO'sPhone#:
Date: 9J- 1 l " `+ *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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