63226D - Misty

7413JANICELN--___---_ -- -- �UL
WILMINGTON, NC 28411 67-219/83
i, f n �D / I � 835
V Date
Pay to the I ,(� � yt: �Lv 1�ee - s a DD UCH Order of � 1 � �-�!'11�'.
Im Bank
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QMoost�Convenient
/Bank*
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i:0539021971: 4283445570iI' 0502

G Division of Coastal Mgt. Habitat impact Computer Sheet
plicant: / "�I�Permit #: 6-3 2- Z �
te:
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen
ind in your Habitat code sheet.
bitat 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 Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated fin;
disturbance.
Excludes any
restoration and,
temp impact
amount
Dredge ❑ Fill ❑ Both ❑ Other 19
aV V
Dredge ❑ Fill ❑ Both ❑ Other [!r
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 ❑ Both ❑ Other ❑

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Aci<< r !i _ _ _ s
Name of Property Owner)
property located at -y
01 (Address, Lot, Bloc Road, etc.)
on �es Cr X , in 1vn,,.;,.,,. , N.C.
(Waterbody) (CityfTown and/or County)
e applicant has described to me, as shown below, the development proposed at the above
tion.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in description below or attach a site drawing)
RECEIVED
DCM WILMINGTON, NC
� PR 1 5 2014
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15' from my area of riparian access unless waived by me. (If you
ish to 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.
(Property Owner Information)
Signature
Re
Pnnt'✓r
of Type Nan*
(Ad'acen o , Owner Information)
Si pture n
Print or Typ�,Narne
/-:,NU/� Do,`U s

I vpav thA i own plowty adj., to
I Name of Prwrty Ow"o
(Addrm, LaL Block Road, etc.}
M*4"twwy) iCifyfTown an4vor cm")
Tne ""nl has descnbed t� mo, as s%*wj) Wow, 9* dvvalopm�Ilf oroposed al ?tom csv
taw C�v o0K.(4twi "o, tus osm
- t have obleom's to tNs Proposal
DESCRIPTION AWOR DRAWj*3 OF PROPOSED DEVELOPMENT
(Individual'Propasing devehVivent must 40 in description Wow of att4ch a site dralvtnq,t
RECEIVED
DCM WILMINGTON, NC
APR 1 5 2014
WAIVEfL SECII(L
I
UndWsmno, that a ;-w, d04, Irf-wing 011fags, breaxwaw, &,,tease IA or gtom mug tjo W
J94 a 1-!r4)tmtxn dWw,4,e (,4 1,51 (tt,#11 firl AwA of nPo'-ton am fts Unlem Wajv&4 try me Of yneu
iale It %aPk below)
L��6 .,./
I do wish tc watve me '$ ietaax
wernafit-
(property owner 1"formatio") (AAac,"t Property, {war Infoffnallon)
st

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