69003D - Fish

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SIC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: F1Q� 4 1411 l-i�� Permit #. 00�-1-�
Date: ©4 / q 1�0 ( —1
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.
Disturbance
disturbance.
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and(or temp _
restoration or
temp impact
temp impacts)
impact amount)
tempimpacts)
amount)
,� /
V V
Dredge ElFill ❑ Both ❑ Other
Cf
Q
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
CDaitc
MHCDO
Tyler Crumbley
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
LPO
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑. Fill ❑ Both ❑ Other ElTara
DW Review IZI
Owner
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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Comments
3/9/2017
Anne and Anne and
Kenneth Fish Kenneth Fish TD Bank 225 $200.00 GP 69003D SF rc

DIVISION OF COASTAT MANAQ ENT
` ADJACENT RIPARIAN PROPERTY 0 R NOTIFICATION/WAIVER FORM
Name of Individual Applying For Permit:
Address of Property:' ?lo tease KJ S w
(Lot or Street #, Street or Road) .
3ru ns w I - CA LOuhT
(City and County)
I hereby certify that I own property adjacent to the above-referenced_property. The indivic
applying for this permit has described to me as shown on the attached drawing the development t
are proposing. A description or drawing, with dimensions, should be provided with this lettei
I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coa
Management, 127 Cardinal Drive Extension, Wilmington, NC 28405 or call 910-395-3
within 10 days of receipt of this notice. No response Is considered the same as no objectia
you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house or boat lift mus
set bck a minimum distance of 15' from my area of riparian access - unless waived by me,
you wish to waive the setback, you must initial the appropriate blank below.)
(" 6 I do wish to waive the 15' setbac . k requirement.
.I do not wish to waive the 15' setback requirement.
Sign Name Date

Name of Individual Applying For Permit:
Address of Property: ' yG ?6 600s e L,y
(Lot or Street #, Street or Road)
(City and County)
I hereby certify that I own property adjacent to the above-referenced.property. The individ,
applying for this permit has escribed tome as shown on the attached drawing the development t ,
are proposing. A desc '1 Eton or drawing, 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 Coas
Management, 127 Cardinal Drive Extension, Wilmington, NC 28405 or call 910-395-35
within 10 days of receipt of this notice. No response Is considered the same as no objectio,
you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house or boat lift must
set bck a minimum distance of 15' from my area of riparian access - unless waived by me.
you wish t. waive 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.
-i -zo/;7
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