26971_CAMERON, EVERETT_20001013

13
CAMA and DREDGE AND FILL -�-It' 269, 71_C
G E N E R A L
PERMIT
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
PROJECT DESCRIPTION
Pier (dock) Length
Groin Length
number
Bulkhead Length
max. distance offshore
Basin, channel dimensions
cubic yards
Boat ramp dimensions
Other
Phone Number
State %✓ �-- Zip
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.
_ applicant's signature
,
issuing date
permit officer's signature
expiration date
attachments
application fee

Personal Account Information
ADJACENT 1I'ARLAN PROPERTY OwNER STAIMM '
(FOR A FIERIUNCO VERED BOA7- LIPM
-
AOQ-
I ctr-dfy that r own property adjacent to g
(N, '=e of Property Owter)
�ropem� located ac - &IV Q &djV/
(Lot, Block, Road, etc.)
on ri'iy Oon.o m rl44-17>& RE-:? cf4 N,C-
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that
locadc4n, and, : have no obj=lions to his proposal. I understand that a pierfuricovered boat lift
must beset back a minimum distance of tlneett feet (15') from my area of riparian a=ss unless
waived by me.
do not wish to Waive the setback requirement.
_ I do wish to waive that setback : Nuirement.
I)ESCRIP"I'ION AN-D/OR DF-.AWT iG OF PROPOSED DEVELOP.NMN'T:
(To be filled in by iAdividurtl proposing development)
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any
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I� Signature
print or Type Name
Telephone Nunbe-
Date: 71 ,),.2 t,,) C-