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-04-2010 09:47 AM Richard 9 Gant Jr.DDS 6926697
twr w sv 1N.v4y 1FA VYIllarmon 910,2157-Q32
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MCMR
North Carob$ DePaVwt of Enwmmmt end Natural Rewumm
D"ron of Coalal Metw mmm
Ivednlel F. ENVY, ocrlvw Ctisse�e !�onwr dreebr
Authorl=d Agent Consent Agr"mant
^/ �— _ Is horaby SAodzed to
,v�aAS" .
in order to obtain any LAMA Pal - I NO required for the pmperty listed below. The eulfwelizat
Vec fk actlultles desWbed in the attached sketch.
LOCATION OF PROJECT:
3�1 �Ac S�C't J— S
....Qc..�.. _._
'ROPERYY OWNER MAILING ADDRESS:
J70 DCJrAJac�
PHONE NO-9 10 (D � C)
UTHOROW AGENT MAILING ADORES;
P0, :2> dx.� (ad1.
Sin M„&J C. �2`6 ( t �A
PNON! NO. ;nature of Property Owner.
;nature of Authorized AWt
Date: /i 4 U
P.01
p.2
0. Rose Jr., eembiry
on my behalf
is liirrdeed to the
(a
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I/09/2010 13:16 7046377788 ROWAN PRIME CARE
VS MAIL
PAGE 04
Drvi-sioN of COA► AL XA'jNAGE_v1EKT
ADJACENT RIPAR*A i PROPERTY O SA�'Y•ENiENT
6-a
•
1 hereby C!erdfY that 1 own propaty Ad�t to
ropertY located at -i a r l.M&6 j
p
on
p licMls phone
�Caiume of Property O�rner)
l 0-
I
mo
ck, ock, Road,) N C
in
(roar► ind/or County)
e40-34' Mailing Adat�:
FP — r—
He/Sho has described to me as shown Wow the development iW&c u ptoPwsias at mat ioc ltion.
and I have no objections to the proPasal•--
--_ ..._ ,)"CRXMo N AND/OR DRAWING OR PROPOSED DEVELOPMIt:NT'
(Ihd hddua[,propatsiag development mat. in drs too below or arm h a sitedraWix� .
F,f czo�r s-�rn WaSkc-. i ►+� a6A I"r(-
f-At A 61jek+.-Re.wto%)'e. w""Z1 e4 coKcrc-t-e b 6-CMA e-p r fi r7
if you hart. objections to what Is being propole4, yo-a nnw Autry Se Wsbn Of C0"U1 Management (DCM) in i g
within 10 days of receipt of this nOtiM Qarrespnndeaee sbr aM be na&d to 127 Ca7dlnal Drfye Ext.WiltaingtA1ti NC
DCM representatives cam also be eontacteed at (910) 796_7ZIS5 R�a noticed pr CFrt� N
& ffllt9 is . ed fife so ed 1 if 4�-�
(Property Owner luiortnstttae.)
Signature
Print or Type Name
Mailing Adgdess
ir
NCL �AQ1r
City /.Stado / zip
Telephone Nwnber k 6 J(0L 0(
amparian Property Orraar Information)
Si
print or Type Nam
MAMag Addren
City / State / Zip
TeiePhoae Number �.�J "�L� �•
I I C . 1 i-\

IS MAIL
CERTIFIED MAIL R I EMN RECEIPT REQUESTED
DIVISION OF COASTAL NT IANAGEMENT
ADJACENT RIPARIAN PROPE Y
OWNER STATEMENT
I hereby certify that I own property adjacent Jscent to ame of Property Owner}
property located at -YY a e �,,-&'
(Lot, Block, Road, etc.)/'� --- � N.C.
on in_--�..1�-
(Waterb dy)
(Town and/or County)
Applicant's phone
Mailing Address:
.He/She has described to me as shown below the development he/she is proposing at that location,
and 1 have no objections to the proposal. ----------------------
----------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(Individual proposing development must fill in description below or attach a site4rawing)
JAC,(
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in writin
within 10 days of receipt of this a dice. contacted at pond) Correspondence
should be mailed to 127 Cardinal Drive Ext. Wilmington, NC
DCM representatives can also b
No res onse is considered the same as no ob'eetion if you have been notified by Certified Mail
(Pro err Owner Infor on
Signatur
��, f fiv k- • ✓� I G 5,�
Print or Type Name
,304 �� = f ) c Ir2C°
Mailing Address i
(Riparian Property Owner Information)
Signature
Print or Type Name
Mailing Address
r-:+- / CtztP / 7in

)licant:
Permit #:
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen
nd in your Habitat code sheet.
3itat 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 fins
disturbance.
Excludes any
restoration and,
temp impact
amount
S
DredgeX Fill ❑ Both ❑ Other ❑
/
Dredge ❑ Fill Both ❑ Other ❑
7 CY)
ICY
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 ❑

ILEN N. WILLIAMSON
P.O. BOX 1602
SHALLOTTE, NC 28459
PH. [phone]
�. T C �j 1z--
SECL.IRITY
1 SmNcs BANK
u'007 2 290 1:253 17 14301:
7229
DATE
� f v �O J /� 66-7143-2531
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