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DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
I hereby certify that I own property adjacent to BuLff Is Cr Qk L_S+6tk.5-s
(Name of Property Owner)
property located at ��.(ISU-1'� �CLLe �,
nn'�_� (Address, Lot, Block, Road, etc.)
on ��QXP S t.1� 2.e,P�_ in `jKCaAS N.C.
(Waterbody) (City/Town and/or County)
Agent's Name #:
Agent's phone #:
Mailing Address:
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)
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at www.nccoastalmangement.net/contact dcm.htm or by calling 1-888-4RCOAST. No
response is considered the same as no objection if you have been notified by Certified Mail
(Property "Owner ormation)
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STghature
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Print � T Name &Q0J+LVt
at VtW r>'
Mailing Address
(Ri➢arfiaJi YropertbVwneonfor}oation)
Print or Type Name
yel,�a, Z"k,g s
Mailing Address

./29/2011 23:33 9103271433 COASTALMINISTORAGE PAGE 01
AkLt: -kyM�q 41
DIVISION OF COASTAL_ MANAGEMENT
AD A ENT RIPARIAN PR RE
CERTIFIED MAIL TURN RECEIPT REIQUEStED FICATION FORM
��` t5 r S s
l hereby certify that I own property adjacent to
(Name of Property owner)
property located at
(Address, Lot, Block, Road, etc.)
on ; V-q is a k- in . N.C.
(Waterbody) (CitylTown and/or County)
Agent's Name #: Mailing Address:
Agent's phone #:
HelShe has described to me as shown below the development he/she is proposing at that location,
and I have no objections to the proposal.
--------------------- -----------------------------------------------------------------------------------------------
,1 11-11 DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
ti (individual proposing development must rill in description below or attach a site drawing)
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If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at wwwAccoaMlmangomentnetJcontact dcm.htm or by calling 1-8884RCOAST. No
rat arse is considered the same as no ob ectlon if ou have been notified by Certified Mail.
(Property Owner Information)
Signature `
Print or Type Name
1?6 Al
Mailing Address
(Riparian Property Owner Information)
Signature
Print or Typo Name
d 6? �-
Mai Og Address
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----) - - - I

licant: C.
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Permit #: 5`�-�Z�
tribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id in your Habitat code sheet.
itat 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 ❑
2 1 6
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Dredge ❑ Fill ❑ Both ❑ Other ❑
G
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 ❑

COASTAL DREDGING, LLC
2075 HWY 172
P.O. BOX 995
SHERDS FERRY, NC 28460
[phone]
PAY TO THE �j �C oe
ORDER OF
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MEMO j fbe-rY��`r C-ry 01
FIRST FEDERAL
HAMPSTEAD, NORTH CAROLINA 28443
67-7194-2532
II■00 368ous ': 2 S 3 2 7 L94 0i: S80600 201AI"
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