68021D - Stafford

SIC Division of Coastal Mgt. Habitat impact Computer $beet
Applicant: Permit #.
Date:
ZlQ C �--
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 O
oosene
TOTAL Sq. Ft
(Applied..for.
Dist urbancetotal
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft
(Antidpated. final
disturbance.
Excludes any
restoration
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 impsd
amount
Dredge ❑ Fill ❑ Both ❑ Other
G%
Dredge ❑ Fill ❑ Both ❑ Other El
Dredge ❑ Fill ❑ Both Other ❑.
Dredge_❑ . Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other El
Dredge ❑ .Fill ❑ Both ❑ Other El
Dredge El 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 Q Other ❑
Dredge ❑ Fill ❑ Both .❑ Other 0

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Mvl AlI ce- Cor6of- '34a-P-R)rj-
Mailing Address: C- RYv �t J�3 EC,5
� aS4- ��1► 2� bed h -}-c ,�,` n , '(� �K 3 3� - �5 �' z.
Phone Number:
Email Address:
certify that 1 have authorized e
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: Mov C 5and frc m 4k,e_ I o �j
�ocec
vvQ�r rnt.-rk- I.) rcpienish 4e- Ios+cLneI berm 1r,+-n--rt 0i my (ybcert~c,,. .
at my property located at O 5 .2--4 Easy
in 6run5w +c I County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature
iL
Print or Type Name
Title