89353A - Staley, Ron and Ruth

�� °" °❑LAMA ❑DREDGE & FILL N9 89353 A B C D
GENERAL Previous permit
PERMIT rS
� 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:
l
I SA NCAC ❑Rules attached. ❑✓ General Permit Rules available at the fallowing link: www.deq.ncgov/CAMArules
Applicant Name
PP Authorized Agent
Address Project Location (County):
City State ZIP 1 % J 1 Street Address/State Road/Lot #(s)
Phone # (_ )
Email
Affected ❑CW ❑✓ EW ❑PTA
AEC(s): ❑ OEA ❑ IHA ❑ UW
ORW: yes/no PNA: yes ono
Type of Project/ Activity C. E
I :
r
ES F-11 PTS
❑SPIMA ❑PWS
Subdivision
City
Adj. Wtr. Body_
Closest Maj. Wtr. Body
Lo' p;er ;J1, ,y,sj_i/
n cw 12_'X Iz` h),,4
I� ;1,n
(Scale:rv'7 5 )
Access Length -
Pier(ddck)length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s) L �.'
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11-1
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1
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Total Platform area
Groin length/k - 1 7
_
Bulkhead/ Riprap length -- 1
Avg distance offshore
Breakwater/Sill _
Max distance/ length
_I,—. — - _
Basin, channel - '- I - ---
Cubic yards
Boat ramp - i
Boathouse/Boatliff
Beach Bulldozing-.__!_
Other
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-
—
-
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-
-
-�
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--
--
1
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SAV observed:, yes no —,� r p f � --
Moratorium: n/a) yes no ?
Site Photos: !yes no_(-
Riparian Waiver Attached: yno:
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—_
_ ;
+
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Ies
A building permit/zoning permit may be 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**
Application Feels) Check Money Order
Per t Officer's PRINTED Name
Signature
iiI2o12.4 3/ 20/2s
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit Ron & Ruth Staley_
Mailing Address 7292 battery Farm Ct Mount Airy, MD 21 771
Phone Number:
Email Address:
ruthiel191 averizon.net
I certify that I have authorized Jiilian Clark / Shane Clark Construction
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: tear our existing dock - using the same
at my property located at 335Ea0e Dr
in Dare 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:
Signature
Print or Type Name
Title
__0l447 ! I ,
Date
This certification is valid through
REC D ED
H O V 0 8 2024
DCM-EC
existing

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: _12on R Ruth Staley
Address of Property: .335 Lagle Dr Kill Devi) Hills. NC 27948
Mailing Address of Owner: 7292 Hattea Farni Ct Mount Airy. MD 21771
Owner's email: _ ntthiei 19l averizon.net Owner's Phone#
Agent's Name. _Lillian Clark Agent Phone#: [phone]
Agent's Email: jillianru shaneclarkeonstruction coin
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 fo 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.)
100 wish to waive some/all of the 15' setback
-OR-
Signature of Adjacent Riparian Property Owner
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owners���
Typed/Printed name of ARPO: Dave or Terri Hendrickson
Mailing Address of ARPO: _333 Eatyle Dr Kill Devil Hills, NC 2794R
ARPO's email` terrihs cn t�iiRmail Com ARPO's Phone#:
Date: - ry,� *waiver is valid for up to one year from ARPO's Signature*
—�—t — Revised July 2021

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David & Terry Hendrickson
337 Eagle Dr
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