General Permits (2349)

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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 f / 110r.
Applicant Name 0 a- to �:-
Address c' s1 ' l r ✓ ,
City
Project Location (County, State Road, Wate Boy, etc.)
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Type of Project Activity s
State
Phone Number tE F1 7 ,,y
Zip,? k 4 ¢: e`
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PROJECT•
Pier •
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distance offshore
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Boat ramp dimensions
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This permit is subject to compliance with this application, site
drawing and attached general and specific conditions. Any 1
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.
In issuing this permit the State of North Carolina certifies that
this project is consistent with the North Carolina Coastal
Management Program.
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applicant's signature
permit otticer's signature
issuing date expiration date
attachments��
apptitation~fee^ ! ' h •�' C
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ADJACENT mmitYAN PROPERTY CyWNM � � _
. .. }• ~ .., J.•1"•; •, .•t ,:/,. •..: •• . yip. ti• .. . 'a. , ' • �'•, • _ ._ '
x 'hereby..certify that I own property adj cent, t j--
"` s ro e.rt -located at _
Name .-Of Xoperty., Owner)
(Lot,, Block, Road, .etc.)
on :I�lF.� n .� .. in C17�u , N: C.
'•; c: (Waterbody) (Town and/or. -County)
.He'' has' �de •scribed to 'me, as shown below, , the development he is
proposing At 'that* location, and; I have no. obj options to his
proposal. ;
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DESCRIPTION AND/OR.'DRAWING OF PROPOSED DEVELOPMENT:
.. (To be filled in by individual, proposing development)
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signature .
Print or Type Name
Telephone Number
Date
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT r'
(]FOR A PIER)
I hereby certify that•I own property adjacent to
Name
located at.Bc('
- on
(Lot, Block, Road, etc.)
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N.C.
(Water Body) "(Tow 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 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 developm,
FILLED IN BY INDIVIDUAL PROPOSING DEVELOPIMiT)
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Name
a, Phone Number

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