89787A - Summers

. 00 CAMA O DREDGE & F ILL
GENEtlAL PERMIT ..,
IE New !X] Modiftcat ion O Complete Reissue
~(l N9 89787 © s
Previous permit _________ _
C D
Date previous permit issued ____ _
D Partial Reissue
As authorized by me Stace of Notth Carciina, ~ or Ell'lironrnern: Qllallty and the C.om;i1 ~ Commisslon ,n .111 area or enworwnenta1 IXlC1Q!rlt pursuant to:
ISANCAC J If~ IA00 0Rulesatl:2Cfied.
Awk<mtName Q\qr-j(. a Ch\ ~i l l\e
Address o1 u C.ecJ. o.. c ~+
0ty W 'l'Y'-0\"\.:\:-Sme _N,~_C.. ___ ZlP
Pilc11e#tj1.S) °l't I -~~'17
email c~<~ ~u.,,n,..w,,..., @ D'\."E.h,. c~
Affected D cw
AEC(s): □OfA
OftW:yese,>
SAVobserved:
Mor.atorium : (f;;)
Site Photos:
Rlparlal\ WaNer Attad,ed:
~PTA
O uw
ffl4: yes/€)
D es
□SPIMA
~ General Petmit Rules av.iitab1e at the follov,q 11n1c www.deo.nc.pJCAMArum
Audlot'fzed~------------------
Project Location (Cow,ty): . &~'-l, i\mJv,s
sv-~ ~#(s)-..,_,--r6_t:~~~--c' ,--------
2 C, G r:::o,,s:s\f ?o-,. J..'--'D .... ·:i...r_,,_, --'-----
SulxfMsic,n . (i rt., 1) ;s~ i?<> j ... J
0:y _~l¼-~·=~~tfur-,__-=--d _____ zw_~_7_~_4~q __
Adj . Wtr. Bocfy_..;,.\)z..=......'!'!{_"l-""Lc. ..... ,_...,CCAdr,,-· -=!-...&i2.=Mr-,._.,,..,..,._ __ (,~)
ClosestMaj. Wtr. Body __ ,_q.-t __ ~~c...==rk~--S~c.~i-4-"-,..,_J ___ _
A buifdlng permit/zoning l>emlit may be required by: _______________ _ D 'tAA/PAt-VNEUSFJBUFFER. (c:irde-)
D See note on back. regarding River Basin rules
~rmitConditlons ______________________________ _
□ See additional notes/conoitions on bade
upimlon Date
~~<.OM1-4t~~CAMA □ DREDGE & FILL
~ "' I GENERAL PERMIT
~~ N?re~?u:~:it @ B
Date previous permit issued _____ _
C D
[E New ~ Modification D Complete Reissue D Partial Reissue
As aut horized by the Stat e of North C arolina, Department of Env ironmen ta l Q ual ity and t he C oasta l Res ources Com missi on in an area of env ironmental concern pursuant t o :
I SA N CAC 1 H • I A CC) D Rules attac hed . IJ Gen eral Permit Ru les avai lable at the fo llowing lin k : www.deg .n c.gov/CAMArules
App lica nt Name Qlq-rl<-a Chi, ~i,~e. s~mmers
Ad dress ~ l \ c.. ed. Q.., C ~t
C ity ~€..lf"'O\'\.:\-: State r-,l C.. Z IP ~ }~ /?...
Pho ne#d'l.5) 1.t I-b ~<t7
Em ail C\\.o..<V--'S.1.,.,..~YV\fv-:-. @ l\'\.'Sb,. Cc,1!'
~EW
D1HA
~PTA
O uw
Affected D CW
A EC(s): □ OEA
ORW :yes@) PNA :yes/€)
Finger pier(s) ____ .-____ _
Tota l Pl atform area '7 'i?.. ~7-V!-
Groin le ngt h/# _______ _
Bu lkhea d/ Riprap length ____ _
Avg dis t an ce offsho re _____ _
Breakwate r/Sill _______ _
Max dista nce/ length __ -, ___ _
Bas i n, chann el _______ _
Cubic ya rds ________ _
□Es
□sPIMA
O PTS
0 Pws
Boat ramp ___ ~-----
Bo athous Bo atlift Ji 1 )2 ~ 1 -------~-;i,,{__~-\,f... \,(\/1:.-,. ~~ Beac h Bu lldozin g ___ -., ___ _
Other__________ _J.r' r -~~~ LJ1~
l \Y ' l
SAV observed: yes ~
M oratoriu m : (j;.) yes no
Site Photos : Q no
Riparian Waiv er Attache d : ® <69
Authorized Agent ____ -,,,-______________ _
Proje ct Location (County): tecf ~i~""-J
St reet A dd r ess/State Ro ad/Lot #(s) ~~(-'o--'t-'-------',#'-1 ________ _
2.C\ G n:Ls S ':1 '?c,..,d.. 'Dr,
Subd ivi sion GG ~SI..( '?u i r,J
City _ _clL!.-k=v--,__tfti.L..!..>oe"-y--=d=------ZIP '<-7 q 44
Adj . W tr. Body Tu'Dt 4, \ ~ fZ..\\cex: (~an/un k)
C losest Ma j . Wtr. Bod y _ ___:~_~_l_\:):w·c...::~=..L!.-='-'-r::k-=,____._SL..;o....,,.u,o..=",...,J.,__ __ _
A building permi t/zon i ng pe rmit may be requ i re d by : _________________ _ □ TA R/PAM/NEUSE/BU FF ER (circle on e) Permit Co nditi ons ___________________________ _
D See note o n back regarding River Basin rules
D See addi ti onal notes/cond itions on back
I AM AWARE OF STATU TES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJ ECT AND REVIEWED COMPLIANCE STATEMENT. (P lease In itial) ______ _
Agent or Ap pl icant PRINTED Name ~q ~ ..
Signature **Please read comp li ance statement on back of permit••
.!> aoo . cyE :>-so Signature
f,lr,_f t..3
Applicatio n Fee (s) Chec k #/M oney Order Issuing Date Expi ration Date
''
;«/~1z!CAMA □ DREDGE & FILL
} GENERAL PERMIT
N9 89787 C 'D
Previous permit ___________ _
Date previous permit issued ______ _
New ~ Modification D Complete Reissue D Partial Reissue
As authorized by the State of North C'.;'"olina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
I SA NCAC ' 1 / ., D Rules attached . QJ General Permit Rules available at the following link: www.deq.nc .gov/CAMArules
Applicant Name --=---''-----'--'---(=--....:1...c· ---'· =--... ---------'''-' --'-'-1"1 __ , _
Address -------"=--=--'---'---=--=--i ____________ _
City __ _:__ ______ State _...:....___~ ___ ZIP __ ....:..:....()_/_l...-=--
Phone# (_I _)----=--=----------'-------
Email __ __;__ __ --=--...:..:cc...:..:_.:._:_:___--==----'=----'--"---...:...:...;.;...: _______ _
Affected □ CW
AEC(s): □ OEA
ORW : yes/n9
□Ew
01HA
□PTA
Ouw
PNA: yes/no
□Es
OsPIMA
Shoreline Length_➔~--'-'-"------·~--...:....,.:.;,__,.._
Access Length ________ _
Pier (dock) length _...c:.._ _ _;_ _ _;__J_' •_· ,~
Fixed Platform(s) _______ _
..J ..
Floating Platform(s) ______ _
Finger pier(s) _________ _
OPTS
0Pws
., ~~ \
Total Platform area-=--=-------'--'---1---,..---1-..-4---+---,.......;.----
Groin length/# ________ _
Bulkhead/ Riprap length _____ _
Avg distance offshore _______ i---+---'-~_._
Breakwater/Sill _________ 1--t-----1-+-+-+-+-+-+
Max distance/ length ______ _
Basin , channel ________ _
Cubic yards _________ _
Boat ramp __________ _
Authorized Agent ______________________ _
Project Location (County): -----=-=-__:__:ci:..=....:::....:....:.-=-------------
Street Address/State Road/Lot #(s) __ .:.....:__....:.._ ___________ _
t,..
Adj . Wtr. Body ___ .:.._ ___ .:....:.... ____ ......t...___:_...:..:..;....:... ___ (.nat/man/unk)
Closest Maj. Wtr. Body + ! ' I
'''" J
,; .1
J...
Boathouse/ Boatlift / t.-.t..-....:4.--4-~r-""'i~
""
.
J
...
'r ,~~~~~
Beach Bulldozing _______ _
Other ___________ _
---------------...,....-t
SAV observed: yes no
Moratorium : n/a yes no -+-
Site Photos : yes ' no
Riparian Waiver Attached : yes ~ !1 9
A building permit/zoning permit may be required by: ____________________ _
Permit Conditions ________________________________ _ □ TAR/PAM/NEUSE/BUFFER (circle one)
D See note on back regarding River Basin rules
D 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 Fee(s) Check #/Money Order
Permit Office r's:J>RINTED Name 1 ~ A)
Signature •
I f '·S
Is suing Date
7 • ..
Expiration Date
N.C. DIVISION OF COASTAL MANAGEMENT
RECEI\/E C
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL · RETURN RECEIPT REQUESTED or HAND DELIVERY AUG 2 1 2023
DCM-EC (Top pqrtlon to be completed by owner or their agent)
Name of Property Owner: "{}1 o.,r /,__+ Ch risli'n e, S\L,fY) vn e.(J
Address of Property: ;J.61 Gra.ssy '""Po,nt:.Dc 1 He..d-{:a,c£ /\CC o/. ltJ'-/'-/
Mailing Address of Owner: /). II &.oku: S+, J3eim11V1='7 ACC c:)8"0 / ~
Owner's ernail:c/ark.,suJnMc:,cseffi5Q .Cmz Owner's Phone#: '-kJ.,5' -(;.5:2-2,niJ
Agent's Name:__________ Agent Phone#: ________ _
Agent's Email: _______________________ _
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adlacent Proparty Owner)
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
pemit has described to me, as shown on the attached drawing, the development they are proposing. A
desaiption or drawing. with dimensions, must be provided with this letter.
/
1/ I DO NOT have objections to this proposal. __ I DO have objections to this proposal.
ff you have objections fo what ls being proposed, you must notify Ille N.C. Division of Coastal
Management (DCII) in writing within 10 days of receipt of this notice. Conespondence should be
malled fo 401 S. Griffin St, Sa 300, Elizabeth City, NC, Z1909. Dell ~ CM also be
contacted at (252) 2&f.3901. No response ls considered the same as no objection if you haw, been
notified by Certified llail.
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 riprap revetments). Jlf you wish to waive the setback, you must sign
the appropriate blank below.) / /........_ ~-/J
I i ) ,· ,I (<, < , ,/)
I DO wish to waive some/all of the 15' setback ,,,::: · '---..:..-.. -' _., {) t :· _'.tt-ll.t rl i' A-z
-OR-
✓· Signature of Adjacent Riparian PrntH!t:tv Owner
I DO NOT wish to waive the 15' setback requirement (initial the blank) ___ _
/l 4 ----
Signature of A"acent Riparian Property Owner: / iU-" --_. __ ._)
/?/ I
Typed/Printed name of ARPO: 2 ,-,,rt t11 :Er\f f;;lk-----t-Jo n1\I 13N ciuJ
MaiHngAddressofARPO: :':l ?f /4J<:;A:§$l-\ J?OiN\ f<,Y) · /.-tfrz..f.fD1ZQ I ,J?.,,,
_./
ARPO's email: "?) it),t i-\.u;k.e, ) Ao.ti · C.D'M ARPO's Phone#: 7.,P 1 ~ -i I~ -1 / t:-,J
Date: ';ti f 11.z (1122,q -w&iver is valid for up to one year from ARPO's Signature*
l I Revised August 2022
N.C. DIVISION OF COASTAL MANAGEMENT RECEI\IED
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL · RETURN RECEIPT REQUESTED or HAND DELIVERY AUG, 2 1 2023
(Top portion to be coc by owner or their agent) M-E C
NameofPropertyOwner. {!) ar-/L+ _/'\.1'1S{ioe ... ~v·11n:1e cS DC
Address of Property: c96 / (3 {(t,SS y Y (f)~nf--:O c I t-fe..dpr'I'~ NC, d--1-q l/Y
MailingAddressofOwner. alt Ceda.c St, ]e.lmc1-n::l: NC. c7~d/d}. J
Owner's emait:l!(arksJro Q)if.Se.,rrim @QlC)wner's Phone#: '-IJ.S:-{;,S;J. -~D
Agent's Name: _________ _ Agent Phone#: ________ _
Agent's Email: _______________________ _
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 desaibed to me, as shown on the attached drawing, the development they are proposing. A
descri7. or drawing. with dimensions, must be provided with this letter.
,.~ DO NOT have objections to this proposal. __ I DO have objections to this proposal.
ff you have objections fo what is being proposed, you must notify the N.C. Division of Coastal
Management (DCII) in writing within 10 days of receipt of this notice. Correspondence should be
mailed fo 401 S. Griffin St, SM. 300, Elizabeth City, NC, 27909. DCII representatives can also be
contacted at (252) 2fU.3901. No response is considered the same as no objection if you have been
notified by Certified llail.
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 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 ~~ L ~
7 Signature of Adjacent Riparian Property Owner
-OR-
I DO NOT wish to waive the 15' setback requirement (initial the blank) ____ _
Signature of Adjacent Riparian Property Owner: ~4-f ~
Typed/Printed name of ARPO: ~#f._c....,,., ~ fa o,,.., .,_, $ f;r /2 ~ e ~ ( (.
j,
MaiHngAddressofARPO: Z // 4 ~-/,} C"-( c u 1/-'-r-/.-for) ;1,,C2 7f o/1/
1
ARPO's email: 4? ~ #fj)c:-?<-/"1 I 6:. I<-, ~ OA ARPO's Phone#: 2 5 2 -.:2 tf' -.:2 5/ > ;
Date: f5 ,.. Jtf ~ ~ 5 "Waiver Is valid for up to one year from ARPO's Signature*
Revised August 2022
■
Original Proposal
Proposed pier location
Shore -up erosion by installing wood bulkhead (approx . 35 ft)
■ Swap areas
Additions 08/15/23
35 ft wooden walkway from base
of pier up toward house
Add additional r i p rap from edge
of existing bulk head to base of
pier (approx . 20 feet).
RECEIVED
AUG 1 4 2023
DCM-EC
"muttNNE ®cAnnA ❑ CREME & FILL (ll� N9 89787 (� s c o
IMb GENERAL PERMIT pprreviouusspermitissued
(NNew VIModification nComplete Reissue ❑Partial Reissue
As authorized by dle�+� SState� of North Carolina, Deparprent or Emeomlenral Qualky and the Coastal Resource; Commkow In an aremimK a of environmental ncem pursto.
I SA NCAC �atn , 1 2,00 C❑++ Rules abachad. [X Germ al Remit Ridesaialhbte at tho folkrwtrrg Uric- H{y,�:s!€st esgav/�'erwn^�
AWIc,,t Nano CIW-K d CYrtS in2 JSA.evtfrter.S Authorized Agestt
Address Atk ceotcLr Reject Location (County): Any_
City mwor . state Z'` c ZIP _2 g . �.� street Addrea State RcaWLot #(S)
PhoneDili-
Emad c(a.+K Sw,yt.rn,p�K Q nn'$�y._Cc m Subdivision ..._
A.I
coy_ w d lap 2�tky4
Affocmd OM M W ®PTA DES ❑pfS Aty. Wtn Body �,�Lzs�i rN.2atS )�'ltex• (r�gerysadt)
AEC(sk [JOEA ❑FHA ❑uw SPIMA ❑PWS Closest plat. Wv: Boil?`ar-k Sei��
ORW: yes, f�d PNA: yes10
of Project/ Activity COAN6,ca- S�lr l ty+/ y` 143, •`(;` Z0. love, -
Type
Lf`23' sht `xZ3' t'x�a+a (Scate:N7$ l
Access Length �• ~�q
P1er(dock)Iength
FNe�dyflatform(4 'tV x2 3
I x2.'S
Floating Piatform(s) e
Finger pler(s)
Total platform area
•
Groin ten0.th/41--.64 -
Bulkhead/Ripnp length —
Avg distance oNnore
Breakwater/sill
Maa"uncellength `^
goat
other
SAV observed: Ws V11
Moratorium: yes no
Site Photos: no
Riparian Waiver AWe cs(9 l_� -
A building permit(zooing permit mW be tecluired by` _-
Permh Conditions ____-.... __
�s.t,.-.-` - .
U TARiPAwNEusE/BUrFER(circle one)
See note on back regarding River Basin rules
See additional notes/comfdions on back
I AM AWARE OF STATUTES, CRC RULES AND CpNDITIDNS DW APPLY TDTHIS PRD)ECt AND REVIEWED COMPUANtE STATEMENT. (Please ln'itial) tE. /23
e— 4^Q.N4 to . gu M to
r ppli`ant PRINTED area
N N 6 /tz/2za
Signature"Pinso read mmprnntt statement on back of R'
Application Feels) Check A/Money Order
�1)7 /n.�
Sign
Issuing Nate Expiration Date

��`°°" ©CAMA ❑ DREDGE & FILL
3 v GENERAL PERMIT
(Previous permit
Date previous permit issued
0 B C D
New Q Modification ❑ Complete Reissue ❑ Partial Reissue
As authorized by theSttate of North Carolina, Department of Environmental Qualityand the Coastal Resources Commission in an area of environmental concern pursuant to:
r
15A NCAC 1 i k i;\ m ❑ Rules attached. f"�" General Permit Rules available at the following link: wwwdeo nc gov/CAMArules
Applicant Name
rd
City UE'.\State RL ZIP 21®( 7—
Phone # (i{gs) 2$ I — `�-s`j 1
Email K Umme rS @ 1%'\SK _ C Okrn
Authorized Agent
Project Location (County):
Street Address/St/ate Road/Lot #(s)
lot 12 rll S54
Subdivision
City ler%iur . zip 21k44y
Affected ❑ CW MEW © PTA ❑ ES ❑ PTS Adj. Wtr. Body ` G nNO.hs f2 tjArl+er /(rjnan/unk)
AEC(s): ❑ OEA ❑ IHA ❑ uW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body 141 bleAtfl-cXr-k S cs L n J!
ORW: yesco..' yes/ w -A �
Type of Project/ Activity L:ar`a'tTueh- a >
Lf'\c23' seen c-1&.),' I4.t xZ3'
r x Z3� }la
Shoreline Lengthy l J"
Access Length��c
^r VU
Pier (dock) length r x t
Fixed Platform(s) X23 ato d+l'
y` X23' (9'sz3i , N" .ram`
^...du bcsikw�j �` tjc
Floating Platform(s)
Finger pier(s)
Total Platform area rmzl t-
Groin length/H .._
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/Sill '
Max distance/ length
Basin, channel
Cubic yards _
Boat ramp
Boathous Boa[lift Y2
Beach Bulldozing
Other QT
K
SAV
observed: yes Moratorium:
G �
Moratorium: a{ai /ye-s� no
�
Site Photos: grgs+ no j
Riparian Waiver Attached: es (0 �.`� ■
A building permit/zoning permit may be required by:.
Permit Conditions
Agent or Applicant PRINTED Name
W
s
Permit
'411Q
SF fK
r
Nn )
❑ TAR/PAM/NEUSE/BUFFER(circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
(Please Initial)
Signature **Please read compliance statement on back of permit" Signature '
Iacx�.1)� I'� 6h2/zg I�hZiz3
Application Feels) Check N/Money Order Issuing Date Expiration Date

❑CAMA ❑DREDGE &FILL NU 89787 (A) B C D
Previous permit
I�`°""
I GENERAL PERMIT Date previous permit issued
ONew ❑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:
I SA NCAC ❑ Rules attached. M General Permit Rules available at the following link: wvnvdeg nc yov/CAMArules
Applicant Name _
Address
City
Phone # ( )
Email
State ZIP
Affected ❑CW ❑EW ❑PTA
AEC(s): ❑OEA ❑IHA ❑UW
ORW: yes/no PNA: yes/no
Type of Project/ Activity
Project Location (County):
Street Address/State Road/Lot ;
Subdivision
City
❑ ES ❑ PTS Adj. Wtr. Body
❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
(Scale:
onoreime Lengui
Access Length I—�
-
--
-
, t
ri-
Pler(dock)length
Fixed Platform(s)
1 1
j -
Floating Platform(s)
_'"
_
_
—f
—
r
_-
(s) ier Finger
g P
r
Total Platform area
-
Groin length/N
BulkhraP length
Avgdistanceoffshore
-
Breakwater/Sill
'.
i
Max distance/length
r
--f--
t—
-
-
Basin, channel
I
--
Cubic yards
_
Boat ramp
I
_
a -
L-
_ `
Boathouse/ Boatlift ��'
I
It
i
� Y.
`4
- -
-
-
Beach Bulldozing
Other
-�—
—
-
SAV observed: yes no
-
Moratorium: n/a yes no
.,
—
L
- -�
Site Photos: yes no
-
—
Riparian Waiver Attached: ves no
- -_-
--
----,-
_-----
A building permit/zoning permit may be required by:
TAR/PAM/NEUSE/BUFFER (circle one)
Permit Conditions
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" Signature
Application Feels) Check Ji/Money Order Issuing Date Expiration Date

N.C. DIVISION OF COASTAL MANAGEMENT RECEIVED
DJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY 0 C T 1 4 2022
(Top portion to be completed by owner or their agent)
roperty Owner:
Address of Property:
Mailing Address of Owner: c911 Ccct[l�! �� L�mN+Tr NC 0-61 a
Owner's email: dar4ktt"mdrbP&%sn.e&� owner's Phone#: �/o2S-o281 ��o3q�
Agent's Name:
Agent's Email:
Agent Phone#:
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
'�Z I DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what -is being proposea, you must noury me rr. t,, umsmn ut waacm
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
noted 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 slan
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback Nr /A
Signature of Adjacent Riparian Property Owner
ME
I do not wish to waive the 15' setback requirement (initial the
Signature of Adjacent Riparian Property Owner:
Typed/Printed name ofARPO: Je,AJ i5f^fa
&4-404,
Mailing Address ofARPO: ZJ6( tltZA 55`( Portt i. T l< A/> I�i,='CI,20� 1 C , Z?944
ARPO's email: 53b€ilCc lt-Q Lnttn i c. & n ARPO's Phone#: U,1 - I r Z - .11 6 7
Date: la I It / Z L *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

N.C. DIVISION OF COASTAL MANAGEMENT
JACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
ERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
party Owner:
a.r /t_ y-
Address of Property: ab ( l^rf
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Mailing Address of Owner: a((
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Owner's emaiI:C/CLfkJttMvnCrSC
fnsn.Corn Owner's Phone#:
Agent's Name:
Agent's Email:
Agent Phone#:
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.C. Otvision 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.)
I DO wish to waive some/all of the 15' setback /
Signature of Adjacent'Riparian Property Owner
-O R-
I do not wish to waive the 15' setback requirement (initial the blank)
/-
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: /''%a 7-
Mailing Address of ARPO: '? 77 r a L,, lc 4 d. 14. - � ,UC 2 7 % c/ '�
ARPO's email: !1 R %i`G) e4 , ge eJe , co�i ARPO's Phone#: 2 S 2 - y 3 y- 7e'e2 Z
Date: io - Z �' z�1Z `waiver is valid for up to one year from ARPO's Signature`
Revised July 2021

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