57355D - Bluestein

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY 0'V�1;ER STATEMENT
I hereby certify that I o-vn property adjacent to /.3LL/c�S%G1i rt/ s
(Name of Property Owner)
property located at % lw,4-zCIAC6 lS l2
(Lot, Ikock, Road, etc.)
on , in!�-T/TJ/�L�� ��!/syTLJ N.C.
(Waterbod (Town and/or County)
Applicant's phone #: -i ?9-V Mailing Address: SAS
He/She has described to me as shown below the development he/she is proposing at that location,
and I have no objections to the proposal.
--------------------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(Individual proposing development must fill in description below or attach a site drawing)
/D/-0? 01ifI�
AVA
Jn,�S�s - f-GD•�r
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in writi
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. Wilmington, NC
DCM representatives can also be contacted at [phone].
No response is considered the same as no objection if You have been notified by Certified Mail
(P operty Owner Information)
Signature
Print or Type Name
/Z 70 oe
Mailing Address
(Riparian Property Owner Information)
4- Q.
Signa ure
54 l �r.
Print or Type Name
y `L(v
Mailing Address

Signature form
Page 1 of
From: Tracy Martin <[e-mail]>
To: bsceltbear <[e-mail]>
Subject: Signature form
Date: Sat, May 14, 2011 1:14 pm
Attachments: scan0002Jpg (935K)
Good Morning Mr. Swift
Attached is the signature form with the drawing for Mr. Bluestein's job at 127 Mallard Dr. Hampstead NC 28443.
Please call me with any questions you might have.
Thanks
Sreg Martin
Delta Dock and Boatlift
310-520-2361
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IC Division of Coastal &19t, Habitat Impact Computer Sheet
pplicant:A 6WjA � t � 'n, Permit #:
ate: 91'-2
� % I
:scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
ibitat 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 final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
D(A)
Dredge ❑ Fill ❑ Both ❑ Other i
� u a
(0o
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 ❑

DELTA DOCK & BOAT LIFTPO BOX 3632
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TOSAIL BEACH, NC 28446 8313
PAY S �5 _ /
THE DATE OR I 66-30/531 l
ORDER OF (�i� /� '^ _ 365
$�_
First Citizens DOLLARS
o.
firatccItl ena. (f Q co ,
FOR L� vl i g':�q-2