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CAMA and DREDGE AND FILL 65r
G E N E R A L �%,
P E R M I T,L;�
as authorized by the State of North Carolina
Department of Environment and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC
Applicant Name Phone Number ' 1
Address
j
City State zip
Project Location (County, State Road, Water Body, etc.)
Type of Project Activity
PROJECT DESCRIPTION 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 become null and void.
This permit must be on the project site and accessible to the permit of-
ficer when the project is inspected for compliance. The applicant certi-
fies by signing this permit that 1) this project 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.
tip
(SCALE:
V_ applicant's signature
issuing date
permit officer's signature
expiration date
attachments
application fee

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ADJACENT RIPARIAN PROPERTY OWNER STAMUEN'T
(FOR A PIER/MOORING PILINGS/BOATLIF IBO. THOUSE)
I hereby certify that I own property adjacent to A-13 R "Qv 6— 's
(Name of Property Owner)
property located at , _ AELe Zy-,:� NT S
(Lot, Block, Road, etc.)
on in 01U YTA'L. N.C.
(Waterbody) (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/mooring
pL'ings./boadliftiboathouse must be set back a minimum distance of fifteen feet (15') from my area
of riparian access unless waived by me.
I dkAot wish to waive the 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
Print or Type Name
Telephone Number
Date: Z- I
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ADjACENT RIPARI N PROPERTY OWNER STATEMEENT
(FOIL A PIER/MOORING PILINGSIBOATIWTIBOATHOUSE)
I hereby certify that I own property adjacent to p th ►.S(r-- is
(Name of Property Owner)
property located at 3 D >~%_ Ti _ ZC qi CIs
(Lot, Block, Road, etc.)
on ¢a nth C LFED'. in D &1r-=k^1Alr , N.C.
(Waterbody) ('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; mooring
pilings/boathftlboathouse 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 the setback requirement.
I do wish to waive that setback requirement.
----
DESCREMON AND/OR DRAWING OF PROPOSED DEVELOPMENT:
t (To be filled in by individual proposing development)
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Print or Type Name
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Telephone Number
Date:
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