24378_TEMPLE, BERLYN_20000103

Tk
CAMA and DREDGE AND FILL
G E N E R A L 243 _
PERM I T
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
Address
City State Zip
Project Location (County, State Road, Water Body, etc.) -
Type of Project Activity
PROJECT DESCRIPTION SKETCH
Pier (dock) Length i
17
Groin Length
number
Bulkhead Length
max, distance offshore
Basin, channel dimensions
cubic yards
Boat ramp dimensions
Other
i1
0
(SCALE: O o )
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 issuing date
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 th P ,
is consistent with the North Carolina Coastal Management Program.
applicant's signature
permit officer's signature
expiration date
attachments
application fee

ADJACENT RIPARIAN PROPERTY OWN,R STA
TIIENT
(F01[ A rIER/UNCOVEREd BOA2, I.dFT)
I hereby certify that I own property adjacent to
's
01 PrpUM v wnerl
K
He h`L� ciescri�ed to me, as shown below, the developmn, he 71
Iocation; and, _I.have ago objections to his proPo'�S at that
must be yet back a p1°Po�. I underst&ad tUi a pier/uncovered boat lift
minimum distance of fifteen feet (IS') frown my a of riparian access unless
waived by me.
I d&Ad wish to waive the setback requir=enL
I q wish to waive that setback mquiremept,
DE.SCIUPM`ATi AND/OR DRAVdWG OF PRO' , ,
ITo be filled ur pot � Dxivi�ujph ENT:
... hY irrda;Vual PmPosin
qw-�V' O C
Ix
Print or Type Name 14-
�el:
Tephone Number j�
Date:

ADJACENT REPMIrAN PROPERTY OWNER S"TA
(F01[ A tIER/UNCOVEMO BOAT Ids
I hereby certify that I own property adjacent to is
ame oT Property caner•)
ProPe located at : ' av- �
(Lot, Block, Road, etc.)
on
in_(y4'at,ody) �-.��� �,,� N.C.
==ems_ _-�
He h-� d "cried to me, as shown below, the de�reio �
location; and, -I have no objections to his pm�' he is Proposing at that
must be set back a riinimum distance of fifteen (St j aP 1ex'/un�vered boat lift
waived by me, f riparian access unless
- -- I JAQt wish to waive the setback
require3neni.
I.09 wish to waive that setback ZCquiYemen?,
DESCIUP.-114)1N AND/OR DRA► WING OF PRO L, :
(To be, filled in by i •earl ' 7e D ENM°UPb'ENT:
S•
f
Pint or Type Name
7, '700.7
Telephone Number I
Date: