89247A - Atkinson, Ralph and Sandra

�Acwr.4 ❑CAMA 0 DREDGE & FILL Na 89247 ;:a B C D
? GENERAL PERMIT Previous permit
Date previous permit issued
0 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 I l i ,;- , ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name
Address
City State ZIP
Phone # (_ )
Email
Authorized Agent I
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ cW ❑ EW ❑ PTA ❑ ES ❑ pTS Adj. Wtr. Body (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ U W ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no; PNA: yes/[ft
Type of Project/ Activity 1 + f
(Scale: )
chnrolina lanahh {._ 'i(1r
Access Length
E
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MUMNs
No
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MENEEMMUMMEMEMEMEMEMMEMEM
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;AV observed:
Moratorium: n/a
;Ite Photos:
kiparian Waiver Attached:
yes no
yes no
yes no
yes no
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.
(
Agent or Applicant PRINTED Name
Signature -*Please read compliance statement on back of permit**
Permit Officer's PRINTED Name
Signature
Application Feels)
Check lJ/Money Order Issuing Date
Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: F�1P1 �if�n S° 1
Mailing Address: /(, 7 P� rate— C°, e-- (za /le,iJ-ArA AJ C_ 2 79N4/
Phone Number:
Email Address:
I certify that I have authorized
> 7-zs3--2/`
Agent / Contractor
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to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: %✓&./-
at my property located at /67 �rrafG C"
in Pf-jr ao5 County.
1 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:
Ja
"�✓ Signature 0� ti014
pCt
Print or Type Name ��^M
Title VV
1 /
Date
This certification is valid through

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: /V>.-)�bl /^ 1-17-1<1AJS0N
Address of Property: 10 17/1?A1F CUVE t)A ,
Mailing Address of Owner: 113 L-crrLr low TZD,3 4..)tLLiAMsQ(.t-0.G VA 231`dS
Owner's email:
Owner's Phone#: 75-7- ZS3—ZIOcl
Agent's Name:/)mc Awon / Agent Phone#:
Agent's Email: >l0.r �// (���� .(-o�
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.
L2 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 notity the N.U. Unnsron or Exastai
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 Cj E I V!
-OR-
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:
ARPO's email:
Date:
ARPO's Phone#:
*waiver is valid for up to one year from ARPO's Signature*
OCT 0 7 2024
DCM-EC
Revised July 2021

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)
Ageo�
Name of Property Owner: Co AtJC L lks I V 419/) )) 6 f? 113 G
Address of Property: I ' I
Mailing Address of Owner 173 P 1 R 4T- CO J C L0 Rc(, 1 F_ t? 1 `'a )?D A)x, Z-7cfvi
Owner's email:
Owner's Phone#: 757 — 7 5;S -^ (flq t 5
Agents Name: Xlly< nn�ry/1 / Agent Phone#:
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacent Property Owner'
I hereby certV 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.
ir-you nave 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 nprap revetments). (If you wish to waive the setback, you must sign
to appropriate blank below.) f�
I DO wish to waive some/all of the 15' setbaczz
/
-OR-
n —
Signature of Adjacent Rip Property Owner
' Icy not wish to waive the 15' setback requirement (initial the blank) _
RECEV V,d In
Signature of en art Property Owner:
OCT o 7 zola
Q � rG Typed/Printed name of ARPORO.Ieln (�±KNY SG✓1
bW t✓ � /�
Mailing Address of ARPO: M. 7 r\ f��d 4-,�- ®CM—E
ARPO's email:
Date:
ARPO's Phone#:
*waiver is valid for up to one year from ARPO's Signature'
Revised July 2021

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