28823_ANGONE, GEORGE_20010912

CAMA and DREDGE AND FILL ('
A
G E N E R A L
Iq
P E R M I T Z, h0i yl�A,
as authorized by the State of North Carolina
Department of Environment and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC
Applicant Name
Address
City
Project Location (County, State Road, Water Body, etc.)
Type of Project Activity
State
Phone Number.
Zip
PROJECT DESCRIPTION SKETCH
(SCALE:
)
Pier (dock) Length
Jul
Groin Length
i
number
u
Bulkhead Length
max. distance offshore
Basin, channel dimensions
cubic yards
j.
Boat ramp dimensions
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Other
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This permit is subject to compliance with this application, site drawing
and attached general and specific conditions. Any violation of these terms
may subject the permittee to a fine, imprisonment or civil action; and
may cause the permit to become null and void.
This permit must be on the project site and accessible to the permit of-
ficer when the project is inspected for compliance. The applicant certi-
fies by signing this permit that 1) this project is consistent with the local
land use plan and all local ordinances, and 2) a written statement has
been obtained from adjacent riparian landowners certifying that they
have no objections to the proposed work.
In issuing this permit the State of North Carolina certifies that this project
is consistent with the North Carolina Coastal Management Program.
issuing date
applicant's signature
permit officer's signature
expiration date
attachments
application fee

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1

ADJACENT RIPARL-�N PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGS/BOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to Z"te'is
(Name of Property ned
property located at 3 l0 a * 01r we, ,
(Lot, Block, Road, etc.)
on �e�-�� , i r �./�.rl� , N. C.
( aterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposire at that location,
and, I have no objections to his proposal. I understand that a pier/mooring
pilings/boathft/boathouse must be se: back a minimum distance of fifteen feet (151) from my area
of riparian access unless waived by me.
I do not wish to waive the setback requirement.
�z I du wish to waive that setback requirement.
ESCRI<TION AND/OR DRAWLNiG OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
f0
f
____.._-__-__ L_
-------------
Signature
IPrint or Type Name
Telephone Number
Date: , S� p

ADJACENT RARLkN PROPERTY OWNER STATE�IE�"I'
IP
(FOR A PIER/MOORING PILINGS/BOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to 's
(Name of oper-ty 0 ner)
property located at --YD C ,
(Lot. Block, Road, etc.)
on , in ..r,� N. C.
4(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location,
and, I have no objections to his proposal. I understand that a pier/mooring
pilings/boadift/boathouse must be se: back a minimum distance of fifteen feet (15') from my area
of riparian access unless waived by me.
I do not wish to waive the setback requirement.
v I d u wish to waive t;-at setback requirement.
DESCRIPTION AN-D/OR DRAWLNG OF PROPOSED DEVELOPtifENT:
(To be filled in bv,i�divuaI proposing development)
O
V I
_________________--____________
SiQ ture I
` -r
Print or Type Name
Telephone Number
Date: CI -�)- -G /