57359D - Hardison

e-16-2011 15:52 From:
To:9102934051 P.4%4
p,3
Nay 15 10 04=00p
ADJ'Accn RIPARYAN PROPERTY O'VVNIER STATEMENT
(FOR A PI'V"00P 7YG P1L17VG&B0A7VF1B0AT'ff0USE)
1 hereby certify that i own properly adjecontto _ � "":a�s
(Name of Property Owner)
propeuzy located at C ' Z-10
(Lot, Block, Road, etc.)
in >
('t�Vatusrbody) , N.C.
°° (Town and/or County)
Appiiennt's phone #: �'/I}-� 9G'" L�� Mailing Address
i �y D�. us arty AD
He has dvsctibed w me, as shown below, the development he is proposing at that location, and, I
have no objeotions to hiss proposal. I understand that a pierlmoori►sg pilings ? boatlifl I boathouse
must be set back a mit um diswac of fifteen feel Q S') Prom my area orripar'an access unless
waivad by me. (if you wish to waive the setback, you must initial the appropriate blank
below.)
I donut wish to waive
I do wish to waive that setback "uirement.
DESCY7.IP')cMQN AND/OR DRAWING OF P1tOPOSED D$V9L6PNIMNT;
(To be filled in by in& ideal proposing dswdopnwn#
(Informmtiott for Property Owner Applying
for Permit)
X 184 DOCTOR WILLII UJ Rn.
Mailing Address
KENANSVILLE NC 28349
City/Statc�Zip
(Riparian Property Owoer laforamboe)
Signature
J'
.01
Print or Type Nair
a CI --�7cjj, ui 70

(-16-2011 15:52 From: To:9102934051 P. 4
Jaa 15 10 04.00p
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NX
KNEW
Norlh Carolina Department of Environment and Natural Resources
Division of C012W Management
Michael F. Fasloy, Governw Charles 5. Jones, Direeter William G Rosa 'r., Secretary
Authorized Agent Consent Agreement
i is hereby authorized to act on my behalf
(PpinfedNams ofA0CM
in order to obtain arty CAMA permit(s) required for the property listed below. The authori72100n is limited to the
specific Sbtis)itles described in the attached sketch.
LOCATION OF PROJECT.
PROPERTY OWNER MAILING ADDRESS:
AUTHORIZED AGENT MAILING ADDRESS:
PHONE NO -
PHONE NO,
Signature of Property Owner, f�
Signature of Authorized Agent: aL � 4' 1

ID Division of Coastalltnpaot Computer Sheet
)plicant: (�C I�.l Permit #:-35�
!scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
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 final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
Dredge Fill ❑ Both ❑ Other
V
O
Dredge ❑ Filln Both ❑ Other ❑
�U V
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 ❑

ANTINORI CONSTRUCTION
145 VIRGINIA LANE
SNEADS FERRY, NC 28460
[phone]
9132
;LJ9/o
m
6
�i $ 3kCi>,
DOLLARS
m
8
Bank of Amerks.
ACH R/T oMM1 °°
66-19-530
�,Sl
0 5-41)(;ah-(06)
5 2 L9901I°
I1°009 L3 2iI° I:053000 L961: 000650

■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
QtgoRAH G ZP�a9
130 ► Nozarn
�►X.tY >I� � � L
a. --) g 413
2. Article Number
(Transfer from service label)
PS Form 3811, February 2004
A.
X�oo ❑ Agent
❑ Addressee
ceived b Prints ame) C. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Service Type
Certified Mail ❑ Express Mail
Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Feel
7008 0150 0000 5544 7152
Domestic Return Receipt
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
57 F)AC-I L
❑ Yes
102595-02-M-154o
A. Si nature
❑ Agent
X
�� .�by (Pri( /�f❑g) Addressee
�RceivedA rn / _ \l7l) �/ G �of D �/
D. Is delivery a&ress different from iterrf f% ❑ YEO
If YES, enter delivery address below: ❑ No
3. Service Type
[;ZCertified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number
(Transfer from service lab 7007 3020 0000 3035 0486
00 C,..... QQ11 OMA r)--fir Rntnrn Rpceint 102595-02-M-1540