67918D - Rabon

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: \V� Permit #;
v
Date: n 2 1 r
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 Name
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
restoiaiion
and/ortemp
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)
Dredge ❑
Fill ❑ Both ❑ Other
j
Dredge ❑
Fil 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 ❑ Other ❑
Dredge ❑
Fill ❑ Both ❑ Other ❑

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l-tk(AkrJLAV MAIL -tiL` 1UIVI Kx,Lb rI KtVVrQA142
DMSION OF COASTAL MANAGEMENT
A. ENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner. 1 ,G 1win, r• ,
Address of Property: 3 D (o Vtr �C .
(Lot or Street #, Street or Road, City do County)
Applicant's phone k: Mailing Address- S3 1 _1 l•Akc L:
o�iti Snr:�rTt Ae aSyo
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this per
has described to me as shown on the attached drawing the development they are proposing. A description of drA
with dim nsms. must bepMvidW with this ktsa'r.
I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCh
in writing within 10 days of receipt of this notice. Correspondence should be matged to 127 Cardinal Drive E
Wilmington, NC 28405-3845. DCM representatives can also be contacted at (910) 7%-7215. No response is
considered the same as no oblection if you have been notified by!Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a minimum distance
1 S' from my area of riparian access unless waived by me. (If you wish to waive the setback, you must initial the
appropriate blank below.)
W1,4
� I do wish to waive the I S' set back requirement.
A— I do not wish to waive the 15' set back requirement.
(Property Owner Information)
Signature
Print or Type Name
6�) 13 , f
Mailing Address
City / Statc / zip
Telephone NumbeQ oZ.� — l 3l
/ arino Property Owner Information)
Signature ga-n d r a- -B c r k v ./
Print oc Type Nome
Mailing Address
3"Olwjl)
City / State / zip
Telephone Number TO .30 092
a , . . .

DIVISIO'i OF COASTAL INIANAGENIErT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
ime of Property Owner:
c-
ldress of Property: 3 0 46 V e r r
(Lot or Street #, Street or Road, City & Cou
��nty)
�plicant's phone #: a 1-1 'day - �%3 Mailing Address: S3 3 Lqg rt vela t1 L i
A C a ? S '4 y
iereby certity that I own property adjacent to the above referenced property. The individual applying for this pei
Ls described to me as shown on the attached drawing the development they are proposing. A description of draw
ith dimensions, must be provided with this letter.
XI have no objections to this proposal.
I have objections to this proposal.
you have objections to what is being proposed, you must notify the Division of Coastal Management (DCl
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive
lilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response is
)nsidered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a minimum distanc
5' from my area of riparian access unless waived by me. (If you wish to waive the setback, you must initial the
3propriate blank below.)
/V I do wish to waive the 15' set back requirement.
y� I do not wish to waive the 15' set back requirement. 7 n .� �r n
Property Owner Information)
ivnature
'rint ,- Type Name
✓la1hn2 Acldres
.C- ar) b
p
Celephone Number ql
<-($Iparian Property Owner Information)
Signature
pl-loytiyvi
L�
Print or Type Name
Mailing Address
City / State I Zip �j,l
Telephone Number �� �� �`S 1 U ��,

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