12162_BURNETTE, JIM_19940323

CAMA AND DREDGE AND FILL /t t f ...
GENERAL
f No -17
PERMIT (°1
as authorized by the State of North Carolina
Department of Environment, Health, and Natural Resources and the Coastal Resources Commissior
in an area of environmental concern pursuant to 15 NCAC ' , ' ' '
Applicant Name `', r Phone NumberAddress
1
i
City State Zip
Project Location (County, State Road, Water Body, etc.)'
Type of Project Activity
PROJECT DESCRIPTION SKETCH !i (SCALE: )
T_
Pier (dock) length i
Groin length
number -
Bulkhead length
ax. distance offshore
Basin, channel dimensions
! r _
v
cubic yards \ / ` ~
,e
Boat ramp dimensions _
I
Other
i
lam— E.
i
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 applicant's signature
come null and void. (e'
This permit must be on the project site and accessible to the permit officer's signature
permit officer when the project is inspected for compliance.
applicant certifies by signing this permit that 1) this pro -
is consistent with the local land use plan and all local issuing date expiration date
ordinances, and 2) a written statement has been obtained from
adjacent riparian landowners certifying that they have no
objections to the proposed work. attachments
In issuing this permit the State of North Carolina certifies that
this project is consistent with the North Carolina Coastal application fee'
Management Program.

r
MR. OR MRS. J. A. BURNETTE 6803
^? �1 NCDL 123285 161144 _1
_ 132 RAND RD. 772-0639 / f
�. RALEIGH. NC 27603 Li 1 g- �� 66 25/531 .1 i
.r 4
3 }
Pay 10 the 1 $ o G
Order of
s 1 r -- ------ Dollars
' NationsBank
NationsBank or Nurth Carolina, N.A.
Raleigh, NC 27611 1 Deluxe Banking Customer
�yl For —
1:053 100 258j: 01, 30 1 27 2ho, ,6803

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT (FOR A PIER)
'i
I hereby certify that I own property adjacent to i 's
property located at
Yot, block, road, etc.)
on��-rlt .i' inL'N.C.
(water body) (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 must be set back a
minimum distance of 15 feet from my area of riparian access unless waived by me.
I do / do not wish to waive that setback requirement.
(circle one)
Description and/or drawing of proposed development: (to be filled in by individual
proposing development)
Signature /
1�
Name
Phone Number

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT (FOR A PIER)
I hereby certify that I'own property adjacent to l 's
property located at /
(lot, b ck, road, etc.)
on �� ��1in wn N.C.
(water body) 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 must be set back a
minimum distance of 15 feet from my area of riparian access unless waived by me.
I do / do not wish to waive that setback requirement.
(circle one)
Description and/or drawing of proposed development: (to be filled in by individual
proposing development)
Signature
Name
Phone Number