87294A - Beasley, Horace

N9 87294
Previous permit
Date previous permit issued
A B C D
JA°°""�CMA [] DREDGE Alt
3 GENERAL PERMIT
❑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. IA -I General Permit Rules available at the following link: www.deq.nc.ggv/CAMAruI
Applicant Name - Authorized Agent i.-, } } (�..:� } n } ..,-. > i. I
Address Project Location (County):
City State ZIP I i l \ Street Address/State Road/Lot #(s) 001 J„ r. 001
Phone #
Email k i h x, c'Slf ..i f (, 9 Subdivision
City zip
Affected ❑ CW `/ EW ❑ PTA DES ❑ PTS Adj. Wtr. Body (nat/man/unk)
AEC(s): ❑OEA ❑IHA ❑UW ❑SPIMA ❑PWS Closest Mal. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
(Scale: J.
Access Length■
Pier (dock) length
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PlatformTotal area
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■■
.19........■
■
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: distance.......
Avg
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing—
�M
.1
®'1
CSi■.■..■
■
IN
NS
S
111
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MEN
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A building permit/zoning permit maybe required by:
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
Signature -*Please read compliance statement on back of permit's
Application Feels) Check N Money Order
( W 161),e)A--, n97aWs, 0 97Z91A -'> NK-+a93A)i
Permit Officer's PRINTED Name
Signature
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address: I1 cci�'/(J�i gMci;l,CC)(VV
r �
certify that I have authorized1—L�-'-
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: % I (��l L� i aCCC'/14Z�
at my property located at too eolz ) (VA �l �
in y County.
I furthermore certify that 1 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:
(i
/ Signature
Print or Type Name
P
Title
tI ( l 1024
Date
This certification is valid through

I
N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONNVAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: 1��/MCI&
Address of Property: �� 6i 7l;,�U r�oG/QT, ZXDktI76A/ PVC
Mailing Address of Owner: ADD C 7�J/�✓ (0141?rI �AL,17V)V IX
Owner's email: A?1ASl?� %PRrm/1 6"1 Owner's Phone#:
Agent's Name:
Agent's Email:
Agent Phone#:
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
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.G. 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 revetment . (If you wish to wainve the s back, you must sian
the appropriate blank below.) j J I n
I DO wish to waive some/all of the 15' setback / ;%//'/yi� /j/ // yy/�
Signature-of(t Ad acc& 1 ar n Propeerr iDr
-OR- hl,
I do not wish to waive the 15' setback requirement (iyfi}ia) the
Signature of Adjacent Riparian Prope Owner:
Typed/Printed name of ARPO: -S
Mailing Address of
AR//PO�: / V C r'rI e�
ARPO's email: ' ( lC eiC� ARPO's Phone#: /� J / ��
Date:.U/r -//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 NOTIFICATIOWWAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: 14o::aC,6F P
Address of Property: ��Cia?B N �r>u�T GOCNtd✓V /VC
Mailing Address of Owner: moo,?� N � /7T Lf�C-ivTDiv iVL
Owner's email: �rl%X�4SlRg�AiYn Owner's Phone#:
Agent's Name:
Agent's Email:
Agent
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacent 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
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.G. uivision or coasrai
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.) _
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
,ER
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner: S Z:S 4-3?
Typed/Printed name ofARPO: c t1V\61�1 R%cm
Mailing Address of ARPO:
ARPO'semail: St„nnY% \0"Q6 •11NAARPO'sPhone#(252� 337— tfSs'i6
Date: l7 'waiver is valid for up to one year from ARPO's Signature*
Revised July 2021