69243D - Francis

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: P"' & SCOL✓` 5� tn(1 Permit #; q2(43—r
Date:
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
FINAL Feet
(Applied. for.
(Anticipated final
(Applied for.
(Anticipated final
Habitat Name
DISTURB TYPE
Disturbance total
disturbance.
Disturbancetdrbance.
Choose One
includes any
Excludes any
total includesudes
any
anticipated
restoration
any anticipateration
and/or
restoration or
and/or temp
restoration or
impacttem
im acts
im act amount
tem impactsunt
Q Wi
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 ❑
Will
Postal
Dredge ❑ Fill ❑ Both ❑ Other ❑
CERTIFIED IVIAIL.- RECEIPT
it (Domestic Mail • •.
to Provided)
Dredge ❑ Fill ❑ Both ❑ Other ❑ru
Dredge ❑ Fill ❑ Both 0 Other ❑
6b Po-Wo Sf
ni
certified Fee
A&Postmari(
Dredge ❑ Fili ❑ Both ❑ Other ❑
Return Receipt Fee
O (Endorsement Required) $I1, I it i r Nore
/
O Restricted Delivery Fee • - - ?j�,

x-,03-2007 le:02 From:
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-OCATM OF PROJECT:
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PROPERTY' OMER MMUNG ADDREM.-
PMMW
PHOMIE No.

3-2eO7 10:02 From: To=8429806 P.
CERTIFIED MAM - RETU_R Il C IPT„rR&2UFSTED
tl • t1 : _ u .mcf:4-Minks
he purpose of this form is to provide proper notice to you as an adjacent riparian property owner to the individual or
dividuals listed below, The CAMA General Permit spplieadon prccedum require that appliutnts provide the Division o=`
oastal Managa rent confirmation that a written stawmem has been obmined signed by the adjacent riparian property ownct
idicoting that they have no objection to the proposed work gr that the adjacent riparian property owners have been notified
y certified mail of the proposed work. Often these forms are submitted to the adjacent riparian property owners by a mnnn
mtracwr or odd individuals acting as an authorized agent on behalf of the applicant.
'his form was sent to you by the rollowing Individual or company designated by the applicant as as
uthorino agent:
ignatttre Dese
Jame of Individual Applying For Permit: , l l t s
kddress of Property: `��(_�j�
( Lot or Street 4, Street or Road)
(city
I hereby certify that I own property adjacent to the above -referenced property. The individual appl, ing for this pej
has described to me as shown on the attached drawing the development they are proposing. A description or draw
with dimensions, should be provided with this letter,
I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coastal Mao9gement.
Cardinal Drive Extension, Wilmington. NC 28405 or call 910.796-7215 within 10 days of receipt otthis no
No response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
i understand that a pier, dock mooring pilings. breakwater. boat house or Bout ilft must be set ba,
minimum d6-tance of 15' from my area of riparian access •.rtaless waived by me. (lf you wish to waive
setback, you most initial the appropriate blank below.)
I do wish to waive the 15' saftck requirement.
///Al—
I do not wish to waive the 1 S' cethnr_tr n•n,rinemnne -VMW,&

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