14555_TOLBERT, JERRY_19950417

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CAMA AND DREDGE AND FILL
GENERAL
PERMIT
14555
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as authorized by the State of North Carolina
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15A NCAC . fA
Applicant Name V-k' % -1 „ .1.�, -1 Phone Number I ` t 1
Address >
�( r
City State _
Project Location (County, State Road, Water Body,,etc.)
Type of.. Project Activiiy / �• l f* ti- r r �: r :/` I G
PROJECT DESCRIPTION SKETCH
Pier (dock) length
Groin length API 11 1 .,
number
Bulkhead length
6.
max. distance offshore (A
Basin, channel dimensions
cubic yards
Boat ramp dimensions
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Other
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CA
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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 be-
come null and void.
This permit must be on the project site and accessible to the
permit officer when the project is inspected for compliance.
The applicant certifies b signing this permit that 1 this pro-
ject Y g g p ) P
ject 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.
I
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applicant's signature
j permit otticer's signature
issuing date expiration date
A
attachments CA r
j'
application fee12

JERRY W. TOLBERT
DL 2102499 PH. 765-7636
P'O. BOX 24711 1919
WINSTON-SALEM, r
NC 27114-4711 19�J
� 66-196;531
PAY TO THE
ORDER �hC v l 18005
$
F/rst Un/on Natlon�l Bank - --DOLLARS
�U� � J o/ Norfh Carot/na
Winston-Salem, N.C. ��--
FOR_4053
10?963�:10618574 x -�
9 9 7 2 u■ �19 __ ._

MEMO
DATE:
TO: SUBJECT:
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�,�..�.z. North Carolina Department of Environment,
Health, and Natural Resources eq printed on Recycled Paper

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'MD! ,t ACKIN7 RIPARTA-Ni PROPE-WFY OWNER STATE IN MINT
I hereby certify that I own property adjacent to s
(Name of Property Owner)
property located at
(Lot, Block, Road, etc.)
in M o 9 f on N.C.
(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,
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To he filled in by individual projosing development)
Si#Kture
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Print or Type Name
Tefepbone Number
Date: 3-,27-,

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