10951_General Permit_19921020

COMA AND DREDGE AND FILL
1 GENERAL �J
PERMIT- -�
as authorized by the State of North Carolina ¢
Department of Environment, Health, and Natural Resources an the Coastal Res urces Commission
in an area of environmental concern pursuant to 15 NCAC % ,41 //,0 / �O
Q_p / Applicant r5--
Name �` Phone Number
Address � �� 2. ,
City ✓� cri
Project Location (County_, State Road, Water Body, etc.)
i✓lam !/��2-a,�,. %--Zi.��./ /�-c.a,�,
T e of P oject^� tivity d�
f!k v 5l `J- " 3 ' 4
PROJECT DESCRIPTION SKETCH P r./f
Pier (dock) length �� L
4 L-
number
Bulkhead length
1 l`n `
max. distance offshore
a
Basin, channel dimensions
cubic yards
Boat ramp dimensions
Other
-tAji,
State 1�--
.Q., . 3 T -
Zip r, y S t! ,
9 (SCALE:
This permit is subject to compliance with this application, site l
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- applicant's signature
come null and void. /i 'J
This permit must be on the project site and accessible to theJ permit officer's signature
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 issuing date expiration date
ordinances, and 2) a written statement has been obtained from
adjacent riparian landowners certifying that they have no �/ C i — /y
objections to the proposed work. attachments
In issuing this permit the State of North Carolina certifies that Cj U o _ /J / , � 3
this project is consistent with the North Carolina Coastal application fee 1 `�
Management Program.

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER)
I hereby certify that -I own property adjacent to
-1. L-
ame
located at '72 0
's property
. on
(Lot, Block, Road, etc.)
in 0-eDv Fd , N.C.
(Water Body) (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 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 that setback requirement. 'cck
I do wish to waive that setback requirement.
Description and/or drawing of proposed development: (TO BE
FILLED IN BY INDIVIDUAL PROPOSING DEVELOPMENT)
�� (
County of
State of
Notary Public
My Commission Expires:
Signature
Name
Phone Number

S'
i
I i I t
W
0

W
FOR A PIER
I hereby certify that I own property• adjacent to
(Name of Property Owner
S3a / I 60&,,A r
's property located at
(Lot, Block, Road, etc.)
on ��.� 1 ; v 6« , in Mi__ 13Eeki 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 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 that setback requirement. Docic
I do wish to waive that setback requirement. 904/c6 FIM
--------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled ir_ by in'lividual proposing development)
sI-a/f ,4 / T �F'aC4 �
gna ure
Print or' Type Name
Telephone Number

i
s'
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