66612D - LaSapio

NC Division of C®artal .Mqt. Habitat Impact- Computer 1heet
)p(icant: � ✓l f � � S 1 Ci �
ate: y .
ascribe below the HABITAT disturbances for the application.
II values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft. FINAL Sq. Ft. TOTAL Feet FINAL Feet
(Applied for. (Anticipated final (Applied for. (Anticipated fins
DISTURB TYPE Disturbance.totai disturbance. Disturbance disturbance.
abitat Name Choose One includes any Excludes any total includes . Excludes any
anticipated restoration any anticipated restoration and/
restoration or and/or temp restoration or temp impact
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge [IFill
[IBoth
❑
Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge. ❑.
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both 171
Other ❑
--t

Computer
Sheet
NC Division of Coastal Ogt. Habitat Impact
Applicant: ' Nv ( p
Date:
Describe below the HABITAT disturbances for the application.
found in yourFHabitatNA
e sheet
All values should match the name, and units of measurement
TOTAL Sq. Ft.
Feet
q
FINA
Anti
(Ant'
(Applied for.
(Anticipated final
(Applied for.
Disturbance
DISTURB TYPE
Disturbance total
includes any
disturbance.
Excludes any
total includes.
any anticipated
Excl
rest.
Habitat Name Choose One
anticipated
restoration
and/or temp
restoration or
tem!
restoration or
tem im acts
im act amount
tern im acts
am(
��
d ❑ Fill ❑ Both ❑ Other
- Dredge g
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ElBoth ❑ Other ❑
Dredge. ❑. Fill ElBoth ❑ Other El
Dredge ElFill ❑ Both ❑ Other [❑

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to D"" i Is
(Name of Property Owner)
property located at `%� �' i3 n' Ai `lam r S � ,) Q / `t
(Address, Lot, Block, Road, etc.)
on / � s� � S�c...1 � �� , in � �� z«
L. N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatio
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;
■ Complete items 1 „2, and 3. A. Signatur a 1
■ Print your name and address on the reverse ❑ Agent
so that we can return the card to you. ❑ Addressee
■ Attach this card to the back of the mailpiece, B. Recei (Print e) C. DatQ of Delivery
or on the front if space permits.
1. Article Addressed to: D. Is d very address di e'enRe 1? Ye
If Y S, enter delivery address below: �]�No
3 >\ E , C\;P� 1-
3.
II I'I'I'I I'll I'I l I I I III IIII II IIII II I Ill III l III ❑ Adult Service Signature
Restricted Delivery
9590 9403 0258 5155 4527 51 ❑ certified Mail®
❑ Certified Mail Restricted Delivery
u nde ❑ collect on Delivery .
must I 2. Article Number (Transfer from service label) ❑ Collect on Delivery Restricted Delivery
❑ Insured Mail
m e. (I i_ 7 015 1520 0003 2460 3 8 4 7 ❑ Insured 0) Mail Restricted Delivery
Po rorm 0011, April 2015 PSN 7530-02-000-9053
L' JS" I do wish to waive ine I Z) ,CtuaUN I VMull
I do not wish to waive the 15' setback requXement.
(Prop. rty Owner Information)
Si ature
It V ; W
❑ Priority Mail Express®
❑ Registered MailTM
❑ Registered Mail Restricted
Delivery
❑ Return Receipt for or g ro i
Merchandise
❑ Signature ConfirmationTM lived b
❑ Signature Confirmation
Restricted Delivery
Domestic Return Receipt
cent Property Owner Information)
<� . ' ." x -IL.
Signature
Orint nr Tvnn Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to , 3�( �(� -- o I
�(Name. f Property Owner)
property located at `, - �� �c�+1 \�(A
C (Address, Lot, Block, Road, etc.
on in N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
a�---Heave, 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)
JUN 212015
pCM WILMINGYr ': :�...
WAIVER SECTION
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.)
wish to waive the 15' setback requirement.
(Property Owner formation)
r
Signature
Print or TVDB Name Print or Tvae Names

4J(16
r
lb
4Xi6
016
4X96
4XIE
Add
Add
Add
i=
28'
24'
20'
16'
R-Section would-
tcessible by a
gang .P-Lank _
ft. of total space
eed to be