11826_JACKSON, DONNY_19930428

O
-Y-
CAMA AND DREDGE AND FILL
GENERALYif�%+
PERMIT
as authorized by the State of North Carolina
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC
Applicant Name
Address
City
Project Location (County, State Road, Water Body, etc.)
Type of Project Activity
_ State
Phone Number
Zip
PROJECT DESCRIPTION
Pier (dock) length_.
SKETCH...
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n' -f
t— r— — �— -- -
Groin length.
number
Bulkhead lengthTF
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 applicant's signature
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.
attachments
issuing date
permit officer's signature
expiration date
In issuing this permit the State of North Carolina certifies that
this project is consistent with the North Carolina Coastal application fee
Management Program.

ADJACENT RIPARIAN PROPERTY OWNER STA
( FOR A PMM)
I hereby certify that, -I own property adjacent to
N
located at
(Lot, Block, Road, etc.)
in , N.C.
(Water ody) Town and/ County)
's property
, on
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 7
S' n ture
Name
Phone Number

ADJACENT RIPARIAN PROPERTY OWNER S
( FOR A -I=W) c l
I hereby certify/that I
located at
own property adjacent to
/:3o 1 X4
ot, biocx, xoaa, etc.
's property
on
�'_%�
-,?=� i n , N . C .
(Water Body) ( own and/o 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)
signa ure r
Name
Phone Number '

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