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CAMA AND DREDGE AND FILL
GENERAL�'�""�
PERMIT
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
Applicant Name
Address
City
Project Location (County, State Road, Water Body, etc.)
Type of Project Activity
State
Phone Number
Zip
PROJECT DESCRIPTION
Pier (dock) length
SKETCH
(SCALE:
)
-
Groin length
number
Bulkhead length—
j
3 ?.;� ;,1
! �t
i
max. distance offshore
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Basin, channel dimensions
3 J
l
..
cubic yards
Boat ramp dimensions
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 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 by signing this permit that 1) this pro-
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.
i
applicant's signature
w�►/qI�
permit officer's signature
attachments
issuing date expiration date
In issuing this permit the State of North Carolina certifies that
this project is consistent with the North Carolina Coastal
Management Program.
application fee

EROSION CONTROL SPECIALISTS 5/91
ATLANTIC BEACH CAUSEWAY
P O BOX 3355 [phone]
:ATLANTIC BEACH, NC 28512
O DER OTO FE /q'
DColC.
FIRST CITIZENS —
T. 1D A j�jT! Flnl CBank a Trust
Company
Atlantic
lc Beach, NC 28612 67T
FOR A4 /ham O
:0531B003001: 1B3421B4853Sne
w Z/ 19&
2388
2388
66-30/531
$ s0.
DPI./� on C.ck.

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
04j iJ O iL i L- 414 TT l (-, s
located at _ 'Z,4Gf Utg6J i 4C,
(Lot, Block, Road, etc.)
�ugty� Svv�.ip
p•Q�CSS C7i-111�11.1Et— in _ ,� i L��li 1C /�c�4C�-} N.C.
(Water Body) (Town and/or County)
property
on
He has described to me as indicated below the development
he is proposing at that location and I have no objections
to his proposal. I understand that a pier, pilings and
dredging must be set back a minumum distance of fifteen feet
(15') from my area of riparian access unless waived by me.
I do not wish to waive that setback requirement.
xI do wish to waive that setback requirement.
Description and/or drawing of proposed development:
(To be filled in by individual proposing development.)
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Print Name
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Date Phone Number

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
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located at _ -?40 C-;J -O al"g. on
(Lot, Block, Road, etc.)
in _ AT "-1 T1G � 6:4(2_A N.C.
(Water Body) (Town and/or County)
He has described to me as indicated below the development
he is proposing at that location and I have no objections
to his proposal. I understand that a pier, pilings and
dredging must be set back a minumum distance of fifteen feet
(15') from my area of riparian access unless waived by me.
I do not wish to waive that setback requirement.
xI do wish to waive that setback requirement.
Description and/or
drawing
of proposed
development:
(To be filled in by
individual proposing
development.)
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
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located at6 L��-
(ILot, Block, Road, etc.)
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dclei Ss in _ A - �[i 1C l�c�er�E N.C.
(Water Body) (Town and/or County)
property
, on
He has described to me as indicated below the development
he is proposing at that location and I have no objections
to his proposal. I understand that a pier, pilings and
dredging must be set back a minumum distance of fifteen feet
(15') from my area of riparian access unless waived by me.
I do not wish to waive that setback requirement.
I do wish to waive that setback requirement.
Description and/or drawing of proposed development:
(To be filled in by individual proposing development.)
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Signature
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