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Applicant: rAf'L LI d D SE Y
Date: ! C) [G Zot
General Permit #:
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Dame
DISTURB TYPE
Choose One
TOTAL Sq. Ft
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
WA t'L
Dredge ❑ Fill ❑ Both ❑ Other
I d or
I60t^ f 2
Dredge ElFill [IBoth [IOther [I
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ . Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

ADJ C(inNT PUPARIAN PROPERTY OWNER SIATEM�h9�
I hereby certify that I own property adjacent to AAA L; GJ , Z 's
(Name ®f property owner)
property located at I � 7 5 A - $ E A � � E O&W-14 140 -
(Address, Lot, MOCK, (Load, etc.)
on n L. O E M R ►A C 6& U �4 , in kv0 " e P6 WAG i /.U�k; N.C.
(�aterrbody) (Cltyifos�rn andlor County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSE® DEVELOPMENT
(irndividugi proposing dedeiopment must fi11 in description below or each a safe drawing)
9 E P t AC C- h --Y A ou P 104 ,q f ,� rr"- ) N sAI;? E l-�P©-F rr" ti fi
WAIVERSECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
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 151 setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner information) (Adjacent PIropeety Owner Information)
(-'Q
SYgnature
EAkc_ w, 9t N D6cL
Print or Type Name
t9?5 pc.8cmf6!21.e ScH�t+ i4
Mailing'Address
®o'er , 0 C. n2`7 97 0
City/6tate0p
asa- 7 53 - 34ok-
Telephone Number/email address
Date
*Valid for one calendar year after signature*
S'i atu e*
u re
Print or Typ Name
1917 Allocmarle &&C-h i
M 'ling Address
r7,nPt,- , i'UC 2-7c)70 -_
cit ���a�e��p
Te1ZlephPpn Number/email address .—
l Jf 12017
Date*
(Revised Aug. 2014)