Poole Bulkhead/Docking Facility (2)

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
.I hereby certify that I own property adjacent to-PACMACCS POO 1 t.-' • . 's -
(Name of Property Owner)
property located at CI l0 3 9 S-1- -
(Address, Lot, Block, Road, et¢.)
on rx.ILS Ghan_Ot , in ( YLSI o v i I , N.C.
(Waterbody) (City/Town andlor County)
The"applica,nt has described to me, as shown below, the developmdnt proposed at the above
locations"
• V. 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)
A tA. cc. S ea Wa. ti -, -foo - -F+ rtocx. -- (i'--f
WAIVER SECTION
. I understand that a pier, dock, mooring pilings, boat ramp, breakwat-r, boathouse, lift, or groin
muM be set back a minimum distance of 15' from my area of riparia access unless waived by
Alf you wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
,. do not wish to waive the 15' setback requirement.
. yI
(Prope Own Information) (Adjacent Property Owner InfA• .tion)
/fi /_.,
Signature Sig .tore*
T'mo-• ‘l W. Srn movwctS Pootre.._.
o r Print or Type NamePrint or Type Nam
8`7 LOA Cb-CLIO rr e�� -I © L �►'\crt_tacSL .
P0. B01- Wiling Address Mailing Address
Kena.ni valet 'V o-k I-6.1 I, NC. 69,,BS''T , ice to Nc.. a-I s-.1©
3 49
City/ ate/Zip City/ tate ip
OC-1 AZTelephone Number/email address Telephone N mbe / ail addr
0.-0?q-t S ,.� A5- 2-6/V
Date Dates
(Revised Aug. 2014)
*Valid for one calendar year after signature*