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Previous permit 0
9N rModificyatioE let! Reissue DPartial Reissue Date previous permit issued
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"i,,d by Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an ar ea of environmental concern pursuant to I SA NCAC
C3 Rules
nt Name attadwq.
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El See note on back regarding River Basin rt

FdAAAA / PDREDGE & FILL 01 - .
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03"EMERAL PERMIT Previous permit #
IN-,,Fw *7Wodification ElComplete Reissue ElPartiall Reissue Date previous permit issued
orized by the State of North Carolina, Department of Environment and Natural Resources
-oastal Resources Commission in an-4qeapf 6nvir?nenerital concern pyrs
I SA NCAC
El Rules attach
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.oval Planning jurisdiction) I\ I I P, t i
;pecial Conditions R -� ki i 1 i v( INA Y\ i-'% A 4

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
I
property located at (Name of Property Owner)
(Address, Lot, Block, Road, etc.)
on , in
(Waterbody) (City/Town and/or County) N.C.
The applicant has described to me, as shown below, the development proposed at the above locatic
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
Atfp
! WAIVER SECTION
understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bac'
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wa
the setback, you must initial the appropriate blank below.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacftfit Prope w r Information)
Sim'atu •e ---�
Sign re
'vile
Print or Type Name Pri t or T p am
d XJ
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