68024D - Forehand

AC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: � Fvy�hakAd Permit #: (e 5762-11-0
Date: d /� /2 o k
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
restoration
and/or temp .
impact amount)
TOTAL FeetF
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts
NAL Feet
ticipated final
turbance.
cludes any
restoration and/c
temp impact
amount
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 ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge 0
Fill 0
Both 0
Other 0

ime) Permit Number amount % Number/
Holder Comments
South
an Brian State GP SF rct.
rehand Forehand Bank 1989 $400.00 68024D 3498D
Refund/Reallocated

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to /J�r ��'� ��� %(, s
(Name f Propert wner)
property located at �� `� f
(Address, Lot, lock, Road, etc.)
on , in
N.C.
(Waterbody) (City/own and/or County)
The applicant has described to me, as shown below, the development proposed at the above location
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)
/0 3 -r
WAIVER SECTION
understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bac
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wz
the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
��ropertypwner Intormation)
agn tune
Print nr Tvne Name
Signature
CNE .T A' 11✓ 44,11
Print or Type Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to _ I,-; 4' e, r"—J'a ^/"f6l S
(Name of Propgrty Owner)
property located at 1;1V U S C,✓r ft- It
(Address,
on , in.
(Waterbody)
Block, Road, etc.
ity/Town and/or County)
, N.C.
The applicant has described to me, as shown below, the development proposed at the above location
I have no objection to this proposal.
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)
v "3
1
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bac
minimum distance of 15' from my area of riparian access unless waived by me. (if you wish to wz
the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
i tune -
Print nr Tvna Name
r Information)

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