71833D - Culp

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to f V ��i l� 's
property located at `Y1�. l L
�- h I�W� CA (Name of Property Owner)
(� _
(Address, Lot, Block, oad, etc.)
oneP�� , in , N.C.
(Waterbody) (Ci ITo n and/or County)
The appl' t 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 AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Date
(Adjacent Prop e Owner Information)
Signatur�y_/P/`��
Print or Type Name
Mailing Adqr6s
W l t I �f �IZW AfC, N 5Z//
Crty/Stat IZ
Telephone Number�fp
,� 0 /9
Date
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to I
�; --) n <- - , t . _ _ A I _ (Name of Property caner)
prc
on
and/or 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 AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
Date
Signature
r 1-10 fz
Print or Type Name _
Mailing Address IV c ��
l-lam / C_ Vl ,
City/state/Zip
91O-Z62 -3971
Telephone Number
Date
(Revised 611812012)

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Date Received
Date De oalfed Check Fmm Name
Name of Permit Holder
Vendor
CMck Numbw
Check
amount
Permlt Number)Commenfa
_Receipt f or Refund/Reallocated
Columni
Column2
Co1umn3
Column!
Column5
Columns
Celemn7
Columns
Column9
7/3/2019
7/3/20191 Nathanial Culp
Nathanial Culp Wells Faro Bank
275 � $ 200.00
GP #71833D
TM rct.8472