57402D - White

Permit #: J + f v
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
TOTAL Sq. Ft.
(Applied for.
bitat Name DISTURB TYPE Disturbance total
Choose One includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.7Disturbance
(Anticipated finalfor.
disturbance.
Excludes anydes
restoration
and/or temp
impact amount)
eet
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
6 l� 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 ❑ Fill ❑ Both ❑ Other ❑

iy.30.2013 06:32 AM Richardson Const & Marine 9108425597 PAGE. 21-/
am a FILL N9 5740'o
PERMIT pmoviandis pwtwt #
cut praAws pwrnit WmW-
As authorized by tho s*,t or Nomh Carmine, mwmvnt cf 2nvArwomont and Naar' I'dewme,
WI and th. Cot urces Camthl"10m, in on W40 of anvirommontal conwr pumutmt to I $A NCAC
YVIO* dtbKftd
Add ? Stream Add Itut �bWRAIV Lot 100(a) JJI
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I ji;W ?OW >,'"A AS 0 "S mm
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(y.23.2013 02:18 PM Richardson Const & Marine 9108425597 PAGE. 3/
es& Atre,
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93
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r-y.23.2013 02:18 PM Richardson Const & Marine 9108425597 PAGE. 4/
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Page 2 of 2

iy.23.2013 02:18 PM Richardson Const & Marine 9108425597
PAGE. 5/
%i v[.I 1 Ga-r► b v- i i rk'
ADSACTI+T RIPARIAN PROPERTY OWNER STATEWI NT
(FOB A PIELMOt7dtl'NG PIL'tNGSVB0ATunlBUATHOLSE)
I hereby certify that i own property adjacent to A.tljti� w�'s
(Nawnt of Jlroperiy Owner)
property located at `
(Lot, R164 Road, etc.)
oil
(Waterbody) ([own and/or County)
Appiicam V3 phone #t Mailing Address+:
He has describedio me, as shown below, the development he is proposing at d,at location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boadift / boathouse
must be set back a minimum distance of fifteen feet (151 rWm my area of riparian a=$$ unless
waived by mo. (If you wish to waive the setbxk, you most initial the appropriate blank
below.)
— I ARXX wish to waive
` ej � -- \ I & wish to waive that setback re quirement.w...._. ,.M.....w .._..M—_-----
DESCRIPTION AND/OR DRAWLNG OF FROPOSLDE D 'Vt✓f,£II'MENT- ------
(To be filled in by individual proposing devalopnKhj)
(Information for Property Owner Applying
for Permit)
� iiing !lddtess
CitylStatel2;p "'
(cleplvnc um r
t ti L'41-3-
(Riparian PrOPtM Owner InformQtion) -
co fi�Pf�
Signature
Print or 1�, a T;atne
Telephone'Number
C-',t__,?

iy.23.2013 02:18 PM Richardson Const & Marine 9108425597 PAGE. 6/
y.14.2013 12135 PM AiaiArd&Vn Const 4 tarIne 9108425697 PwZ. 2/ 2
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