89002A - Sams, John and Robin

DREDGE & FILL NO 89002 `9> B C D
Previous a GENERAL PERMIT Date permit previous
3
[] 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. ❑ General Permit Rules available at the following link: www.de%nc eov/CAMArules
Applicant Name
Address
City
Phone # (_ )
Email
Affected ❑ CW
AEC(s): ❑ OEA
ORW: yes/
Do.%
State
❑EW ❑PTA
❑IHA ❑uW
PNA: yes%no -�
Type of Project/ Activity _F
ZIP ',,d A cI ] `%
'TARS, PTS
❑SPIMA ❑PWS
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Adj. Wtr. Body
Closest Maj. Wtr. Body
(Scale:,=.;. )
Access Length
Pier ( dock) length
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Fixed laPlatform(s)
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Floating
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Finger piers)
Total Platform area
Groin length/#.......,,.
Bulkhead/Riprap length s ,}'
Avg distance offshore
Breakwater/Sill_--
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Maxdistance/length
Basin, channel
Cubicyards
Boat ramp
Boathouse/BoatliR
Beach Bulldozing
Other_
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Gam..
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SAV observed: yes no
Moratorium: n/a yes no
SiteRioPo htWaiver Attached: yes no
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A building permit/zoning permit may be required
Permit Conditions
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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. (Please Initial)
Agent or Applicant PRINTED Name
Permit Officer's PRINTED Name
Signature **Please read compliance statement on back of permit**
t"
Application Feels) Check ff/Money Order
Signature
Issuing Date
Expiration Date

ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Properly Owner:., 0 tAaJ S AM S
Address of Property: Z (Cl
Mailing Address of Owner: (5z /vG W R-\J Z71?2-
Owner's em2S444SdL-@EARTtll.0 k. ;JC•r Owner's Phone#: [phone]b
Agent's Name:
Agent's Email:
Agent
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom Portion to be completed bV 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 (Choose only one)
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 riprao 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
-OR-
I DO NOT wish to waive the 16' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name ofARPO: zvae` t50pENr EDE,u-laa toww .yu
o Ox Mailing Address of ARPO: 00 c0)Fo7on) Oc- 270z_ � g O�K-tE7 l • AG a9sovPhone#: 2S2 iSs
ARPO's email: car¢y•9ao-lE� ARP —
Date: Z ACA(t- 2021- -waiver is valid for up to one year from ARPO's Signature'
✓,a oEF2

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: �rj 5A M-;
Address of Property: 2 lltkT; r i AWt:7< r2t
Mailing Address of Owner: 67xaJ-TVfJ NG SW Z-
Owner's email; Phone#: Z�y 546! 6216
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 properly. 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 dimensio ust be provided with this letter.
I b0 NOT have objections to this proposal. 100 have objections to this proposal.
If you have objections to what is being proposed, you musf notify the N.C. Dlvlslon 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 (Choose only onel
understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of 15' fr m my area of riparian access unless waived by me
(this does not apply to bulkheads or riprap revetmoflts). (If youwisho waive the setback, you must scan
the appropriate blank below.)
I DO wish to waive somelall of the 15' setback
-OR- '
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Properly
T dlPrinted name of ARPO:
YPe a.f q -!a—
�D6NT0fJ tic..
Mailing Address of ARPO: 01(I Qd� /4Nt //
ARPO's email: 0 v ember nri) ARPO's Phone#&P-t)3a5' S9 77
Date: rIgIL 2 r 2 02-waiver is valid for up to one year from ARPO's Signature*
Revised August 2022

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