57429D - Gregory

i if Ny t l m «vMRW:i , v'ayyii RnJ i {i Y1 i Z? 4
-- 71*
k .
'0?�Zz- *ti ,.
04
77
`PJ3 r� �1r%; ji�4+�`n TiL*s��i11D(i:i:Sliai�cr"t%y
V
-•�.__._.�..._ ?i
- 1
G 05ed HrOE-GF9-GW SlE4ua�EMsle;uad dm% 90:0L LLGZ 9L

15 2011 10:08 WR RentatsWR.Rentals 919639-3:)41 'pasrT 5
/14/2011 15:02 FAX [phone] XcGRADY & )ic(,RA,,n Q 002! Dot
" '"ru 0 bi I 1 0-: 5 2 00im, pZ
% It zzau�mlt L M'L si QWW
ADIALA-1 -sam
T?w wzpa" of .iris
m4pokon Pax
eimlhwd CAM.AOcr..i rftVIgft
Cow-IMr
mdr"war. sutumm
Aw 6wn vb%*x,d
j?"Ilcuind dw M*3, hftvo no Objw2jan ID CW prepa"d vVet JIL *W ft "i'j"
b? Qw9AW NMI of ft w"am d w**- Dam Vea rtm, qs gn mm*m d t*w
Ow"tm ar vihm agnird 4* M SMA06wo IBM Ltr of It* spo;owc.
rLis Ithrm wk m% iv v0a OY Wiliindw)
Indiv.dul Amlyun ror PW7"*.
A*k" of PrW*m;
Lts e3r Sbw it, cross or mato
C=—
O*bY mmmiflp dw I no*" pra;*r%)Ammr to tite abovepshuVrpa" T?* tg&
• 4 Pam•j""ftft.Fbr vt
d "Mit- should be 21wided wb
pww.r'-tiv,@ Tx ?E Altg&R'XRW49"%,.MC ZIAW cc, call dAys 4prWootagift
L axdO."ad *v, M, pier. dadL woarwj pilinp, tt�ft:tev,,-,, jb"U wr a
ts, Irvin tw:,
.'Pau woor sjp:w M app-apaism bj*&& L, diao-
Fj� ',5
17--k7i 6c ?&A ap TM"e Itr 15 a-&ak r"L. im�s�
tr
17-
ALA.

D/L/
0 S 67
-Lr Y

icant: 'W itt"15 ��l
7 //31zo( /
Permit #: 41 �-7 VZ Gj J%
;vibe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
d in your Habitat code sheet.
tat 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)
Dredge ❑ Fill Both ❑ Other
Dredge ❑ Fill 0 Both El Other
to
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 ❑

TNF. GLOB[ IN LOWER RIGHT OF THE GHt—
\.iJ1-L3:1
PAY TO THE
ORDER OF - -
SIGNER -...:_ BY SIGNING PUF
i:09L2L55581:
pprnn�
MN 91
North American anking Company,
307791637
NOT VALID OVER FI�IE 11111NED DOLLARS 1122 OG)
_AO REVERSE SIDEBEFORE GASHING
MONEY OPOEP
,crc —AOGE AND OTHER TERMS AND CONDITIONS ON THE REVERSE SIDE AND ON PURCNA9
3700307791637il'