Adjacent Riparian Notification

• ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to P6 BnC 's
Naof Property Owner)
property located at 63 777 / jrk
(Address, Lot, Block, R ad, c.)
on 1C t/ , in aL . J�2 & nuot,4, 44.C.
(Waterbody) Ci /Town and/o#
(City/Town County)
Th='a•licant has described to me, as shown below, the development proposed at the above location.
'L 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 sit d ing)
nt
WAIVER SECTION
I and.rstand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back a
mini ll distance of 15' from my area of riparian access unless waived by me. (If you wish to waive
the t. .ck, 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 require ent.
(Pr. •erty Owner Info ation) (A•'• e Pro• : n - f.rmation)
An . . � j; I /
Si• �t e / Si if
Ai( tc../ AM 4,
Print or Type Name Prit or T p Nae
,
31 / fta z{//e Tr / 34 L t 0,k 5&i
Mailing
ling Ad 1 e ge d lYG $y(0 y Mae
ssr
6ec,c(
City/State/ZipCity t /Zip
qua - X71- 3zz- 1 i 5 - - �z��
Telep4one Number Telephope Number
Date Date
(Revised 6/18/2012)