27595_MILLS, MARVIN_20010313

CAMA and DREDGE AND FILL
.2 7 �95
G E N E R A L
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
Address
City
Project Location (County, State Road, Water Body, etc.)
Type of Project Activity
Phone Number
State zip
PROJECT DESCRIPTION SKETCH
Pier (dock) Length L
--
—�
r e',
i(-
(SCALE:
t ...
I
1
�.
11
Groin Length
number'Y`{
Bulkhead Length
max. distance offshore
j
-
P
Basin, channel dimensions
It
cubic yards
Boat ramp ramp dimensions
Other
1
µF iJ.
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.
applicant's signature
`- permit officer's signature
issuing date expiration date
attachments
application fee
4—

3904
FOLEY & FOLEY CONTRACTORS, INC.
PH. 252-636-2515
1810 OLD AIRPORT RD.
P.O. BOX 3482 66-1185/531
NEW BERN, NC 28564
DATE
PAY = �•
TO THE I � and
ORDER OF- - —� —_—!� • -
fill J11111I ,glltl
j �•,T (�nm+ .i.tl 1!. 1DOLLARS
® A&MAN G LE off
ce
A�� BANK NNew�Bern�NC- 28560
FOR L ! V i1�N�� Ti-_' r� % -Q--E-- - - -- - -----
11'0000 390110 i:0 5 3 1 1 18 5 21:09 3 1000 1601"

03/12/2001 19:13 2522491781 MILLS CONSULTING S PAGE 01
OF; fA2ol XA&
M OLL - �X
Date: March 3, 2001
Number of pages including cover sheet: 3
To:
Attention:
Phone:
MCS
Mills Consulting Services, Inc.
Insurance ----------
P.O. Box 12343
Now Bern, North Carolina 28561
Phone [phone]
Fax [phone]
From: Marvin C. Mills
❑ U rgent
❑ For Your Review
CJ Reply ASAP
❑ Please Comment
Fax: El Other
[phone]
Hi Scott,
On 3-6-01 you visited me with, Brad, and Don holey, to try and get a permit to
build a boat lift and put a roof an same. However due to a new requirement
,you stated I need 75 feet of shore line and Y only had 72.77 feet of shore.
You advised me that if I could get 75 feet of shore line you would issue a perm3
to build the hoatlift with a roof.
Attached is a copy of a Quit Claim Deed from Susanne M. Osgood to Marvin C.Mills
& wife Mary 3o Mills.
The call is for 3 feet of shore line this gives me 75.,7.7"and/Yndicated this
would meet the requirement of the state. etc.
Scott, thanks again for you✓help in advance. If you have any questions
kindly advise. Please advise me when the permit can be issued.
Sincerely,
Ma in C. Mills

'.03/12/2001 19:13 2522491781 MILLS CONSULTING S PAGE 02
No Titla Examination Requested & None Performed
Tax Parcel ID 8 (whole)
Revenue Stampe, S 4)-
Prepared by: Moses B. Lasitter
Attorney at Iaw
New Bem, NC 23560
(File: Z8S10 )
NORTH CAROLINA
PAMLICO COUNTY
Book Page
0362 0153
PILED
PAnICO COUNTY
03/12/2001 4:30 PH
JOYCE E CARAWAN
Register Of Deeds
THIS QUIT CLAIM DEED, made this 8' day of March, 2001, by SUSANNE M.
OSGOOD hereinafter referred to as tor; and MAI&VIN C. MILLS and wife, MAR Y JO
MILLS, whose address is R fleArvh6e. qCrzxeS` 1-0
hereinafter referred to as Grantee;
The designation Grantor and Grantee as used herein shall include said parties, their heirs,
successors, and assigns, and shall include singular, plural, masculine, feminine or neuter as
required by context.
WITNESSETH:
That the Grantor, for a valuable consideration paid by the Grantee, the receipt of which is
hereby acknowledged, has remised and released and by these presents does remise, release and
forever quit claim unto the Grantee all right, title, claim and interest of the Grantor in and to all
that certain lot or parcel of land situated in No. 5 Township, Pamlico County, North Carolina,
and more particularly described as follows:
All that certain lot Qr parcel of land lying and being in No. 5
Township, Pamlico County, North Carolina, and being more
particularly described as follows:
BEGINNING at an. existing iron pipe in the northwesternmost
corner of that tract or parcel of land conveyed to Susan M. Osgood
by Laurie A. Sawyer by deed dated June 30, 1997, said point being
r►'� a common corner with the Grantee herein, (Mills), said point also
being .located on the edge of Beards Creek; RUNNING THENCE
FROM THIS POINT OF BEGINNING along and with the
�\ shoreline of Beards Creek in a northwesterly direction 3.0 feet;
Q a THENCE, North 79' 02' 00" East 6.0 inches; THENCE., parallel
with the shoreline of Beards Creek and parallel with the first call in
x Uj a southeasterly direction 3.0 feet, more or less, back to the northern
?� property line of the;Grantor herein, (Osgood); THENCE, South 791
0 02' 00" West 3.0 feet to the point of beginning.

+ •,03/12/2001 19:13 2522491781 MILLS CONSULTING S PAGE 03
Book Page
0362 0154
TO HAVE AND TO IdOLD the aforesaid lot or parcel of land and all privileges and
appurtenances thereto belonging to the Grantee free and discharged from all right, title and claim
or interest of Grantor or anyone claiming by, through or under Grantor.
IN TESTIMONY WHEREOF, the Grantor has hereunto set his hand and seal the day and
year first above written.
(SEAT.)
Susanne M. Osgood
NQRTH CAROLINA
J COUNT''
a Notary Public in and for said County and
State, do hereb ertify that Susanne M, Osgood personally appeared before me this day and
acknowledged the due execution of the foregoing instrument for the purposes therein expressed.
aCR my hand and official stamp or seal this day of rC 2001.
'
FM Jaytoouaoc�+ $
Kf
Not Public
k•,
My commission expires. 5
R OLINA
P'A1vIIZb COUNTY
The certificate of the foregoing;not is certifi • o be correct. This instrument was
Presented for registration this day and hour, and duly recorded in the Office of the Register of
Deeds of Pamlico County,
This _ZI, day of 2001, o'clock m.
Asst./Deputy Register of Deeds

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual applying for Permit:��.."-11�1
Address of Property:
(Lot or Street #, Street or P.-nd, City & County)
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, should be provided with this
letter.
I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coastal
Management, Hestron Playa II, 151-B, Hwy. 24, Morehead City, NC, 28557 or call (252) 808-
2808 within 10 days of receipt of this notice. No response is considered the same as no objection
if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house, lift or sandbags must be
set back a minimum distance of 15' from my area of riparian access unless waived by me. (If you
wish to waive the setback, you must initial the appropriate blank below.)
(� I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Signature Date
lLL-S �R
Print Name
Telephone Number With Area Code

1
15 NCAC 7H .1102 has been propcsed to be amended as follows:
.1102 APPROVAL PROCEDURES
(b) The applicant must provide:
(1 confirmation that a written statement has-been obtained
signed .by the adjacent riparian property owners
indicating that they have no objections to, the proposed
work, or,
(2) confirmation that the adjacent riparian property owners'
have been notified by certified mail of the proposed`,
work. Such notice should instruct adjacent property.,
owners to provide 'any comments '•on the proposed --
development in writing for _consideratipn by, permitting, _ -
officials to the Division of Coastal Management within
10 days of receipt of the notice, and, indicate that .B'o
response will be interpreted as no objection DCM.
staff will _review all comments and 'determine, based: bn
their relevance to the potential ,impacts of th'e;
proposed . project, . if the proposed project can . b'o,
approved by a General Permit. If DCM staff finds that
the comments are worthy of more in-depth review, the
applicant will be notified that he must submit an
application for a major development permit.
History Note: Statutory Authority,G.S. 113A-...107(a);
113A-107(b);'113A-113(b); 113A-118.1; 113A-124
Eff. March 1,' 1984;
Amended Eff. January 1, 1990; December 1, 1987:,;
�r l+rd i4 i ���L d60i�fillt�t-:�i�i�'ytWil..�w�.sv' __:.,ral�lf��'.1 �'M:;4L`'iw •��'y.ie�rY„�

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PT

y- Cgo r-�,
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03/05/2001 16:53 2527457067 BUILDING INSPECTIONS PAGE 03
d :,
sawn by:
IARD B. HOLLOWELL
TTORNFY AT. LAW
DAYBORO. N. C.
28315
180'MQ 555
NORTH CARQLINA,
A
PAMLICO COUNTY
THIS DEED, made and entered into this 23rd day of Junes.
1975, by and between GARVIN B. HARDISON and wife, VZVIAN B.
HARDISON, of Pamlico County, North Carolina, WIN.IFRED,H.. CRANOR,
unmarried, of Wake County, North Carolina, and 'WYLM& H. W`YNN
and husband, LEO WYNN, of Bertie County, North. Carolina, herein-
after called "grantors", and FRED MILLS, JR. and wife, DOROTHY
S. MILLS, of Craven County, North Carolina, hereinafter called.
"grantees";
W I T N E S S E T H:
That grantors, for and in consideration of the sum
of ten dollars and other good and valuable considerations
to them in hand paid, the receipt of which is hereby acknow-
ledged, have bargained and sold, and by these presents do
bargain, sell and convey to the said Fred Mills, Jr. and wife,
Dorothy S. Mills, and their heirs and assigns, a certain lot
or parcel of land in Number Five (5) Township, Pamlico County,
North Carolina, particularly described as follows:
On the east side of Bairds Creek, bounded on the
west by said creek, on the east by the access .road
shown on the map of Pleasant Acres, prepared by
Darrell D. Daniels, C. E., recorded in Map Book
3 at page 22, Pamlico County Registry, bounded on
the north by the Guy Matthis lot and on the south
by the: lot conveyed to Marvin C. Mills and wife
by deed dated May 1, 1969 and recorded in Book 153
at page 169 of said registry, BEGINNING at a point
in the western line of said access road, which is
located the following four courses and distances
from the control point shown on said map (the northern
terminus of the dividing line between Lots 2 and
3); South 24 degrees 40 minutes West 75.7 feet;
thence South 11 degrees 10 minutes West 73 feet;
thence North 75 degrees East 93.78 feet; thence
with the road edge South 27 degrees 50 minutes East
92.65 feet to the point of beginning and running
thence from said beginning point South 27 degrees.
50 minutes East with the road edge 121.64 feet to
the northern corner of the lot conveyed to Marvin
C. Mills and wife; thence South 56 degrees 28 minutes
West with the Mills north line 332.3 feet to Beard's
Creek; thence northwardly with the creek 162.82
feet; thence North 63 degrees 26 minutes East 343.5
feet to the point of BEGINNING, containing 1.1 acres,
more or less.

03405/2001 16:53 2527457067
BUILDING INSPECTIONS PAGE 04
wo iou W 556
There is conveyed with the above-desciibed lot the
right of ingress, regress and egress.over, across
and upon that certain road referred to and designed
"Access Road" upon said map of record referred to
hereinabove.
The above description is taken from a map and
survey entitled "PLOT PLAN FOR MARVIN AND FRED MILLS"
by Engineering Associates dated April 23, 1969.
Said land is a part of the SECOND TRACT in the
deed from Lydia B. Hardison to Garvin B. Hardison
and others dated September 20, 1966 and recorded
in Book 145 at page 497, Pamlico County Registry.
TO HAVE AND TO FOLD the aforesaid lot or parcel of
land, together with all privileges and appurtenances there -
unto belonging, to the said Fred Mills, Jr. and wife, Dorothy
S. Mills, and their heirs and assigns, in fee simple forever.
And grantors, for themselves, their executors and
administrators, covenant with grantees and their hears and.
assigns, that they are seized of said premises in fee; that
they have a perfect right to convey the same in fee simple;
that the same are free and clear of all encumbrances whatso-
ever; and that they will warrant and defend the title to
the same against the lawful claims of all persons whomsoever.
IN TESTIMONY WHEREOF, grantors have hereunto set
their hands and seals, the day and year first above written.
Garvin B. Hardison
L_ ^� , (SJ
Vivian Bxar ison
(s)
inifred H. Cranor

•03/06/2001 13:54 2527457067 _ BUILDING INSPECTIONS PAGE
01
153 Pa 1e9
r" t
NORTH CAROLINA r.,.
'
ti
PAMLICO. COUNTY
THIS DEED made this the 1st days of Magi
1969, by Garvin B. Hardison and wife, Vivian B. Hardison, of
Pamlico County,`North Carol,lha, Wilma H. Wynn and husband,.
Leo Wynn, of Bertie County,'North Carolina, and Winifred H.
Cranor, unmarried, of Wake County, North Carolina, parties of
the first part, to Marvin C. Mills and.wife Mary Jo Mills,
`
of Craven County, North Carolina,, parties of the second parts
:4;.,•.:
WITN£SSETH: .T dt the. parties. of the f rs t
.
part, for and in consideration of the sum of .Ten (Slo.00)
Dollars and other.goo'd and valuable considerations, paid by
the parties of the second part, the receipt of which is hereby
acknowled ed •have bar ained and sold
9 ► 9 and' by these presents
,
j
do bargain, sell and convey to the parties of the second part,
.
and their heirs, subject to the restrictive covenants herein-
.
after set forth, the following described property, to wit:'
.•
That certain lot or parcel of -land in No.
5 Township, Pamlico County, North Carolina, bounded on
zthe west -by Beard's Creek, and on the east by an Access .
o g' Road as shown upon a m.ap of Pleasant Acres Subdivision
prepared by Darrel D, Daniels,.C.E., dated April 13,
tr<�K 1
r.u.�w 939, recorded in Map Book 3'at page 22, Pamlico
County Registry,
,a.r said lot being more particularly
described as follows: BE at a point in the
1t
°x western line of said Access Road as shown upon said
4 Map,
which point is located the following courses and
"
distances from a control corner marking the north- '
eastern COrner of Lot No. 2 of said Pleasant Acres Sub•
s
agK, division as shown '.upon said Map above referred to, to
�.. ;1
jN►. wit: South 240 40' West 75.7 feet, and South ll° io'
o o West 73 feet; * and North 750 001 East 93.78 feet, and
�-
>
wo South 279 50' East 214,29 feet, to the beginning:
thence from this beginning along and with the western
N line of said Access Road as shown upon.said ma South
'
270 501 East 207.94 feet; thence South 790 0V West
3el.47 feet to a point in the shore line of Beard's
I
. �rroa�flr
�•:
��
'"�ea''r�rr �, *` �f' �i ^�'�^'ti ;=r���p�s r� a �: �r� x.: c.:i•�•rs r �sirsi►v�:.a�r.r
`�+►besus.,�ewawRwKe�-�,e+•--�--^.�,�. - ..a.+,a�wwwa,�
r '

. 03/06/2001 13:54 2527457067 BUILDING INSPECTIONSp PAGE 02
.. i. .. .,y !'yjh'r w.p,e,�,•_+,lrli ^o 'i '1gf�'.S'�i%.t
,. rli? �, •, , "K., i• t ;G `17., t..'4•,'Y\.e "� "-� � � nl r,l '.7 �a.
53, 170
Creeki thence along and with the short line of Beard's
Creek ins northerly direction 72.77 feet to's pointy
thence North 560,281, fast 332.30 feet to the beginning,,.
There is conveyed with.the above described lot
the right of ingrees,.regress and,egress over, 'across
and upon that certain road referred t0 and designated. '
"Access Road" upon. -said map of record refeTred to
h$reinabovP.
The above description is taken from a map and
survey entitled "Plot Plan for Marvin and rred Mills"
by Bnginegring Associates dated 4-23-69. ;
The above lot or parcel of land is -conveyed subject'•
to the following restrictive.and protective covenantst
1. No structure shall be erected altered, 'placed
or permitted to remain on said lot other than for use
as a single family residential dwelling, Only one
residence and such outbuildings as are appurtenant
thereto or incidental to said residence shall be erected...,". go
or allowed to remain on said lot.
2v No dwelling shall be'erected.upon said lot which '
shall have a market value at the time of completion of
less than $79500.0O, exclusive of land and exclusive.
Of . the cost of construction of'any garage and other
outbuildings.
3. Such dwelling and'outbuildings erected upon said
1
lot shall be constructed of material of ood .
quality and appearance,. and all construction shall*be
Performed in a good workmanship manner.- No dwellin
or other outbuilding shall be constructed of imitators.
siding of any kind. Any outbuilding constructed on
said property shall be of similar materials quality t ?'
and workmanship as the dwelling,
4
4. No dwelling or other building shall be lot v
nearer than thirty feet from'the means water lines gd
aeardta Creek. No dwellingor ,
other. building shall •�''•'•'
be located nearer than fifteen feet to any side line ' of any lot.
• g. The rear ,
or aastern five feet of said propex.t ' is reserved for the y'•
utilities.installation and maintanance of
. No noxious - or offensive trade
or activity shall
be carried on upon said lot nor sh him b ; thereon which may be or become a nuisance anything
.annoyance!' r•;:;:., ''
to the neighbprhood.
4.
-r•r^+`-
t.�' '�#t' y�1r � ,. q<>• .. �. .r.' _• ,1i '.7r5 !` � sp--Tit +� -

03/06/2001
13:54 2527457067 BUILDING INSPECTIONS PAGE 03
•, a,� :.Y,,.✓i:".7F.hf"j`.R•t""+':., a"�''. a, y:. r. s,„ ., -
w ';NNtYa"s`i+!•'•� � �,.Ca» � "� Yi' ;:�?...s „�,�... ��.... : �+• �,;: +-.�...:Mrirw..._ - -
v °
1G
T, bb structure pf a temqnrary character, trailers
building -or.
mobile home, tent, shack, barn or other r..
!,; •:
structure o£'a temporary nature, shall be -used or
allowed to remains an said plo,perty at any dims. �.
8. The above restrictive covenants an¢ conditions'
are to run with•the sand and form a part of a general
pi.an for the benefit.of all owners of property shown
upon said,map hereinabove referred to, and said
are and shall be binding upon the- ranteet,
covenants 9 p 9
their successors, heirs and assigns.
Enforcement of these restrictive covenants and
�.
„. conditions shall be by -a proceeding at law or in equity
against any person or persons violating or attempting
C ?.
to violate, any covenant either to restrain violation
or to zecovor damages. Invalidation of any one of
these covenants, by judgment or court order shall, in
no way affect, any of the other provisions which shall
remain in full force and effhCt.
N
1
r
TO HAVE
HA AND TO HOLD the aforesaid l of or.
parcel of land and all privileges and appurtenancea thereto'" ,:.
belonging to the said•.parties of the' -second part, their heir, '
and assigns, in fee simple, forever,
And the sai3 parties'ef the first part
for themselves and their heirs, executors and 'administi'ators,
,.
tuna
0 '
nt with
h said parties .
p of the second part, their heirs
-and assigns, t2at they are seized'of said premises in feat `
'
and have the right to convey the same in fee simple, that the
same are free and clear from all encumbrances except the,
restrictive covenants hereinabove set forth, and that they
will warrant and defend... e th •
title to the same against the
_lawful claimer of all persons whomsoever except as to said
restrictive covenants
t:
Y
'�•
,�, •fir �
, ;�., ,r�:.
.'o �,-..\. _ .. .r ..

03/05/2001 16:53 2527457067 BUILDING INSPECTIONS PAGE 01
NORTH CAROLINA PREPARED BY SUMRELL, SUGGt CARMICHAEL,
STUBBS & PERDUE, P.A.
COUNTY OF PAMLICO
THIS DEED, made and entered into this the 27th day of
November, 1978, by and between ALVIN R. DIXON and wife, RUTH W.
DIXON, of Craven County, North Carolina, parties of the first
part; and MARVIN C. MILLS and wife, MARY JO MILLS, of Craven
County, North Carolina, parties of the second part;
W I T N E S S E T H
That the parties of the first part in consideration of
the sum of TEN DOLLARS ($10.00) and other good and valuable
considerations to said parties paid by the parties of the second
part, the receipt of which is hereby acknowledged, have bargained
and sold, and by these presents do bargain, sell, and convey unto
the parties of the second part, said parties' heirs and assigns,
the following described property, to wit:
All that certain tract or parcel of land lying and
being situate in No. Five (5) Township, Pamlico County,
North Carolina and being more particularly described as
follows:
Beginning at a point located in the centerline of the
30 foot right of way shown as an access road on that
certain map entitled "Plan of'Pleasant Acres Subdivision,
Pamlico County (Hardison Property)" recorded in Map
Book 3, Page 22, which said"beginning point is located
the following courses and distances from the intersection
of said centerline with the northwestern line of the 60
foot right of way of N. C. Secondary Road 1117: North
310 45' West 217.43 feet, North 611 15' East 141.4 feet
and North 230 30' West 144.72 feet to the point of
beginning. Running thence from said point of beginning
so located as follows: North 65° 36' East 295.04 feet;
thence North 23° 30' West 200 feet; thence South 65°
36' West 295,04 feet to the centerline of said access
road; thence along and with said centerline of the
access road South 231 30' East 200 feet to the point of
beginning.
Together with a nonexclusive easement for ingress,
egress and regress over that certain right of way
designated as an access road on that certain map entitled
"Plan of Pleasant Acres Subdivision, Pamlico County
(Hardison Property) recorded in Map Book 3, Page 22, in
the Office of the Register of Deeds of Pamlico County.
This conveyance is subject to the right of way of the t
access road as shown on the above -.referenced map.

03/05/2001 16:53 2527457067 BUILDING INSPECTIONS PAGE 02
TO HAVE AND TO HOLD said property and all privileges
and appurtenances thereunto belonging to the parties of the
second part, said parties' heirs and assigns forever.
And the parties of the first part do covenant that said
parties are seized of said premises in fee and have the right to
convey same in fee simple; that the same is free from encumbrances
and that said parties will warrant and defend the title to the
same against the lawful claims of all persons whomsoever.
IN TESTIMONY WHEREOF, said parties of the first part
have hereunto set their hands and adopted as their seals the
typewritten word "SEAL" appearing beside their names. All done
the day and year first above written.
zu_ (SEAL)
ALVIN R. DIXON
(SEAL)
RUTH W. DIXON
NORTH CAROLINA
CRAVEN COUNTY
I, �'` a NotaryPublic in
and for said State an County, Certify that ALVIN R. DIXON and
wife, RUTH DIXON, personally appeared before me this day and
acknowledged the due execution of the foregoing instrument for
the purposes and intents therein expressed.
Witness my hand and Notarial Seal this 27th day of
Nfiyember, 1978.
Notary Public
J`Commission expires:
3
NORTH CAROLINA
PAMLICO COUNTY
The foregoing certificate
a Notary Public of Craven County, Nort Carolina, is certified to
be correct. This instrument was presented for registration this
day and hour and duly recorded in the Office of th gister of
ee s.of Pamlico County, North Carolina, in Book �� at Page
his day of November, 1978, at
o'clock )OT.M,
e
BY:
RE IST OF DEEP$ REGISTER OF DEEDS

03/01/01 14:43 FAX 004
CENT R PARIAN PROPERTY OW
NER WNSR •T)►TEKEP]T
I hereby certify that I own property adjacent to
property located at
(lot block road etc
on beard's Creek ' ' ra ahoe
in P
(body of water) (town)
North Carolina in pa,T,li,, County. The proposal has been described to
me as shown below; the development, a pier/bulkhead structure; and the
(circle one
proposed location, and I have not objection to the proposal. I under-
stand that if the development is a pier, it must be set back a minimum
distance of 15 feet from my area of riparian access unless waived by me.
I do/do not wish to waive that setback requirement.
(circle one)
Description and/or drawing of proposed day opm t:
individual proposing development). ii*i STA
STRUCTURE AND THE DISTANCE BETWEEN EACH RT Lim
OF .
A - 100� 90�
13
filled in by
LOCATION OF THE
THE WATER.
Tdw
f
(Original must be retained in the Inspection Department)
1J0AT4 0VJP- wya4
(,o'k 1ti w 6 4 k wirx
.3G
ern. osaoaa
Signature
/Iq Ion
Date
o1uSOPn12- M
Name (please Print)

03/01/01 14:43 FAX 05
�k
5
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(iN D STATE$ POSTAL SEAVIM
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