92260A - Good, Ted

#F]New
❑CAMA ❑ DREDGE & FILL N° 92260 A B C D
i Previous permitGENERAL PERMIT Date previous permit issued
❑ 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.deq.nc.gov/CAMArules
Applicant Name
Address
City
Phone # ( )
Email I-
( Authorized Agent
. Project Location (County):
State ZIP Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. War. Body (naUman/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
Shoreline Length
Access Length
Pier (dock) length _
Fixed Platform(s)
Floating Platform(s)
Finger pler(s) _
Total Platform area _
Groin length/q _
Bulkhead/ Riprap lei
Avg distance offshor
Breakwater/Sill _
Max distance/ lengt
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing_
Other
SAV observed:
Moratorium: n/a
Site Photos:
Riparian Waiver Atti
A building permit/zoning permit may be required by:
Permit Conditions
(Scale: ; )
TAR/PAM/NEUSE/BUFFER (circle one)
See note on back regarding River Basin rules
ElSee 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** Signature
Application Feels) Check q/Money Order Issuing Date
Date

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED !A61L RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner.�e-j) UGI
Address of Property: 37-0 GOJ
Mailing Address of Owner:
Owner's email-+ed"y�U)16C;V.a0Owner's Phone#: &-
Agents 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.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 943 Washington Square Mall, Washington, NC 27889. 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 rampbreakwater, boathouse, lift, or
groin must be set back a minimum distance of 15' from my area of ri rian access unless waived by me
(this does not apply to bulkheads or riprap revetments). (If you wish t waive the setback, you must sign
the appropriate blank below.) t
I DO wish to waive sometall of the 15' setback
OR
I do not wish to waive the 15' setback
Signature o%,f iacent Riparian
Signature of Adjacent Riparian Property Owner:
Typed)Printed name of ARPO:
Mailing Address of ARPO:
the
Owner
r�
ARPO's small: (•I,,,f I/Ff0.__ i6/�� gRPO's Phone#: _ ZOZ�rZ'i1. Z -Oji
Date: PISAIA MI., 17-0L4 'waiver Is valid for up to one year from ARPO's Signature'
Revised July 2021

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
Address of Property:
Mailing Address of Owner: rk.iv�C—
Owner's email-+d�-caJLQ) (Q,LOV, t0440wner's Phone#: S: 3 70 — —O
Agent's Name:_,______,__ _-_ Agent Phone#-
Agent's Email
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacent Property Owners
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
YI 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 943 Washington Square Mail, Washington, NC 27889. 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 toC waive the setback, you must sign
the appropriate blank below.) i f� 'J� ' •_v.�
I DO wish to waive some/all of the 15' setback,
Sign—aTure of Adjacent Ripdrian operty Orvne%
OR -
A .SSOC�TI
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner Black Rock Development Owners --- Assoca6on �—
Typed/Printed name of ARPO: nI�x 14
° Wry
Mailing Address of ARPO:
ARPO's email: (�. ARPO's Phone#:
Date: t �P �a *waiver is valid for up to one year from ARPO's Signature"
Revised July 2021

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