67920D - Crouch

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: ( � L Permit #: �'Ic-o
Date:
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurem(
found in your Habitat code sheet.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft
(Applied for.
Disturbance total
includes any
anticipated
restoration or
tempimpacts)impact
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
amount)
TOTAL Feet FINAL Feet
(Applied for. (Anticipated f
Disturbance disturbance.
total includes Excludes any
any anticipated restoration an
restoration or temp impact
temp impackamount)
n l
Dredge ❑ Fill ❑ Both ❑ Other x
)lJ
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 ❑
Dredge ❑ Fill ❑ Both Q Other [IDredge
❑ Fill 0 Both 171 Other ❑

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
(Name of Property Owner)
property located at 9 3 A ,'veC 1/_ I ✓
(Address, Lot, Block, Ro d, etc.
on Ci.r7 �� �� r'� :�� T , in N.
(Wa erbody) (CItyrT wn and/or County)
The applicant has described to me, as shown below,
to ation. ZI
' have no objection to this proposal,
I have objections to this proposal.
the development proposed at the abc
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual roosin development must rill in d " tion below or i ii h a site drawin
5,1z A lve4Z7 P�.1, �� 5 ���� ex�s il,
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or grc
must be set back a minimum distance of 15' from my area of riparian access unless waived
m (If you wish to waive the setback, you must initial the appropriate blank below.)
i W11 I do wish to waive the 15' setback requirement. j
I do not wish to waive the 15' setback
(Property Owner Information)
ign re
ho,"Ald A, Cc u l�
Print or Type Name
Me
i�g Agd/'ess A /I --
Prop)" Ow ainfo
ULve,r- /,..,a n cl: s
Print or TypeName
26 � Live.(' veJ' br.
A,Wling,Address

ADJACENT RIPARIAN PROPERTY OWNER STATgMENT
I hereby certify that I own property adjacent to R F, to l.. rn u C k 's
(Name of Property Owner)
property located at o2 /C , v et4l
(Address, Lot, Block, Ro d, etc.
on C44 in N.C.
4 (Waterbody) (City/T wn and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locati
- I have no objection to this proposal. i
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individ gj,,pposing develo' ' oit must rill in dd ption below or !k oh a site drawin�t�j
7zo' exfss.v��;I�i�t,�S,�/;��
WAIVER SECTION
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.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner I ormation)
lgn re
/t A-)AId /g,
Print or Type Name
/� .
(Ad j
Print or Type Name
dde')
fg,gonation)
Malg Ac)dress
Mailing Address,

M.
-n
Domestic thall Only
SOUTHPORT? NC 28+w�
Certified Mail Fee
ee
$3.710
-ci 459
U-)
U-)
$
01
Extra Services & F (check box, add fee as ate)
❑ Rol— R-.iA " i
Return Receipt $
Postmark
C3
0 termed Mail Restricted Do rvery I
I.Irle
E::3
0 AdWt Slqnaz— Rmu"d
❑ Adult Signature Restnted Dalwy $
Postage
C3
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0 16
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$
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any
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M : Domestic rhail Only
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Certified Ma I Fee ; 3 .30 ru
Ln .Si$ -7".i
Ul tra 7ervices r.ees (clhackba.K, add Wqp to)
El Retum Receipt (hard
O 0 Retum Receipt le4aptwjc) $ Postma
0 Certified hail RWnctec Delivery $ Here
E] Adun re Required $ Signature 1,10
C:3 E) Adult Signature Restricted Delivery $
C:3 Postage I Cl . 47
S Total Postage anti Ffr -.tz
47
Sent To
lot I Ver-
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234 RIVER DRIVE, SOUTHPORT