10842_General Permit_19920721

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LAMA AND DREDGE AND FILL
GENERAL
PERMIT a Na 104
as authorized by the State of North Carolina
Department of Environment, Health, and Natural Resources and the Coastal Resouls Commission
in an area of environmental concern pursuant to 15 NCAC i /' 4 ,,, ` I
Applicant Name �t VA td,1 Phone Number
Address S c; E- C.
City. ! t. ! State Zip
L
�� � �
Project Location (County, State Road, Water Body, etc.)
Type of Project Activity
PROJECT DESCRIPTION I SKETCH
Pier (dock) length
Groin length
number
Bulkhead length
max. distance offshore
Basin, channel dimensions
cubic yards
Boat ramp dimensions
Other
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.
(SCALE:
applicant's signature
permit officer's signature
l
issuing date expiration date
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.

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
( FOR A
I hereby certify that�I own property adjacent to
's property
Name
located at / 3-ro, on
(Lot, Block, Road, etc.)
(Water Body)
in , N.C.
(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 ��
NORM
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)
S gnat4ee
Name
Phone Number

e r '`
on
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
Name of Property Owner
(Waterbody)
's property located at
(Lot, Block, Road, etc.)
in , N.C.
(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 be filled in by individual proposing development)
Signature
Print or Type Name
11
Telephone Number