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Coastal Earthworks, Inc.
1955 Middle sound loop Rood • Wilmington, NC 28405 • Phone: [phone] - Fox. (91
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Coastal Earthworks. Inc.
1955 Middle Sound Loop Road • Wilmington, NC 28405 Phone: [phone] • Fax: (910) 6f
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C Division of Coastal Mgt. Habitat Impact Computer Sheet
3licant:
le.
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
Ind in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated fina
�itat Name
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/c
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts)
amount
W
Dredge Fill ❑ Both ❑ Other ❑
5'2!5
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Dredge ❑ Fill ix Both ElOther El
Dredge Dredge ❑ Fill ❑ Both ❑ Other ❑
ed a Fill ❑ Both ❑ Other ❑
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
A. Si nature
■ Print your name and address on the reverse
❑ Agent
so that we can return the card to you.
❑ Addressee
■ Attach this card to the back of the mailpiece,
B. Recei ed by (Printed Name) C. Date of Delivery
or on the front if space permits.
d6
1. Article Addressed to:
D. Is d ivery address different from item 1? ❑ Yes
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If YES, enter delivery address below: ❑ No
► z 19 .S40-1C#4 Ave.
3. Service Type
❑ Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
2. Article Number 4. Restricted Delivery? (Exba Fee) ❑ yes
(Transfer from service label) 7008 1830 0000 0976 4553
PS Form 3811, February 2004 Domestic Return Receipt
- 102595-02-M-1540
Dredge ❑ Fill ❑ Both ❑ Other 171

COASTAL EARTH WORKS INC. 3750
[phone]
1955 MIDDLE SOUND LOOP ROAD ss-7t72/253t
WILMINGTON, NC 28411
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Pay to the A 1
Order of_ i V I$ 4 0 0"
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COOPREA�R'wV nVE
BANK „\
WILMINGTON,NC�
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1: 2 5 3 17 1 7 281: 16900 10 30 21
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