69213D - Ewing

NC Division of Coastal Mgt. Habitat Impact Coml
Applicant: D 0 Ack� J-- # ��.- I -� —
Date: 0 5/,� cA /( 7
Describe below the HABITAT disturbances for the application.
All values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
Fit
(Applied for.
(Anticipated final
(Applied for.
(Ar
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disl
Habitat Name
Choose One
includes any
Excludes any
total includes
Ex(
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
tern
temp impacts)
impact amount)
temp impacts
am
O
Dredge ❑ FillyBoth ❑ Other ❑
Dredge ❑ Fill Both ❑ Other ❑
I d00
I od
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both 0 Other ❑

.17.2017 02:54 PM Gordon 7043331359 PAGE.
HAND DELIVER 699 <�v #
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A P,I,ER/MO0RIN4 PILIN'OSIBOATL,IFTBOATbiOUSE)
I hereby certify that 1 own proPc acijac2t to[_ 's
b 61 L114. ;t` o .k (Name -of Property Owner)
properly located at
(Lot, Block, Load, etc.)
On- C r-�n n e- 1 _ —, in Q,&)r, , J 1.0 1 � 7
�l� Z L—, N.C.
(Waterbody) (Town and/or County)
Applicant's plane if: q (Oq� M20* Address:, rl? _ Lz.Ly tl u4 e 5 t"
OCeo-yl ZS( e, Aw.'Rew.
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boailift / boathouse
must be set back a minimum distance of fifteen feet (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 4kng wish to waive
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF�PROPOSPD DML.OIyM1;NT!
(To befil/ed!.by in (Evidwal proposing developmend)
(Information for Property Owner Applying (Riparian Property Owner information)
fir Perm it)
"'78 L `tj rue ; 4 _
Mailing Address Signature
CCe:C,n ��l �c a8�le� C', ,� �1 o myj
GitylState/Zip Print or Type Name

nkofAmerica-Eastla 5/19/2017 8:41:04 AM PAGE 2/002 888-294-5658
16 17, 11:20a p,1
HAND DELIVER .;
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(MR A PIF_RMOORDVG PILING&B OA TLXFTIB 0.4T.i9'OUS.E)
1 hereby certify that 1 own property adjacent to,
(Name -of Property Owner)
property located at _� �V2vJ� � S-T
(Lot, Block, Road, etc.)
on `/�Tt"�?.QLo �c , in CX:�1 �Sl 3 C- N.C.
(Waterbody) (Town and/or County)
Applicant's phone # r110�C;� ":sMalling Address. $ J �y2C�,-S
lie has described to me, as shown below, the development he is proposing at that location, and,1
have no objections to his proposal. I understand that a pierhnooring pilings / boallift / boathouse
must be set back a minimum distance of fifteen feet (IS) from my area of riparian access unless .
waived by me. (if you svish to waive the setback, you must initial the appropriate blank
below.)
I do not wish to waive
I do wish to waive that setback requirement.
----------- --------- ------ ----------------- --------- ----------
DESCRiPIION AND/OdZ DRAWiI\`G Op' PAOI'bS*kD bk' IE'LOPIVlt1V'){'_.. .
(To be filled in i y individual proposhig development)
(Information for Property Owner Applying
for Permit)
Mailing Address
City/statelzip
(Riparian Property Owner Information)
���� Signature
_____ Print or TypeNarne

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