10799_General Permit_19920625

Applicant Ni
Address
City
Project Loca
CAMA AND DREDGE AND FILL
GENERAL
PERMIT 9 10799
as authorized by the State of North Carolina %
Department of Environment, Health, and Natural Resources and the Ob Refit /ea�gti�mission
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in an area of environmental concern ursuan to 15 N/CAC
�� G��i'?�%`(f / 1 .✓�f ( Phone Number `e 2-2- 0
oji (County, Stgxe Roac
Type of Project Activity
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State e Zip
Water Body, etc.) e+_.:7n /. Grp':z
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PROJECT DESCRIPTION SKETCH (SCALE: )
Pier (dock) length r7' F /
Groin length ✓ y�f
number ✓
Bulkhead length
max. distance offshore
Basin, channel dimensions,
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
come null and void.
applicant's signature
This permit must be on the project site and accessible to ih
permit officer'sisignature
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
issuing date expiration date
ordinances, and 2) a written statement has been obtained from
adjacentP
_ _ riparian landowners c,& __rti.fy_ing__.thaL. ave no
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attachments
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objections to the proposed work. y �
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In issuing this permit the State of North Carolina certifies that
this project is consistent with the North Carolina Coastal application fee
Management Program.

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER)
I hereby certify that -I own property adjacent to
located at
RI l--
's property
on
(Lot, Block, Road, etc.)
in 4�, 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 fifteen feet (151) 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)
JL
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t1
II's
q0c
Signature
Name
y/9 Y73
Phone Number

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER)
I v,-/reby c rtify that I own property adjacent to
- � /�
's property
located at
. on
( Lot, Block ,RCoa d, ptc . )
�- 2
in %c , 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 fifteen feet (151) from my area of riparian access
unless waived by me.
41�-
I do not wish to waive that setback requirement.
I do wish to waive that setback requirement.
Description and/or drawing of proposed development:
FILLED IN BY INDIVIDUAL PROPOSING DEVELOPI�N
o '!')
r r•-�r- a •�. �•�•
Signature
Gt FCbeE vwt (�
Name
qtq - g97-/y32_
Phone Number
( TO BE