77401_Lynne Fortunato_20200930

ii2K)
("AMA/ ('1DREDGE & FILL D- W t 0 �() 77401A (B� C D
i-1-11
GENERAL PERMIT l._J Previous permit# uj�
ew Modification E 1Complete Reissue flPartial Reissue Date previous permit issued 4/14
As authorized by the State of North Carolina,Department of Environmental Quality 1 I (��\VO
and the Coastal Resources Commission in an area of environmental concern pursuant to I5A NCAC Il
cached.
Applicant Name Ly yNne "Fo<- m11 A Project Location: County Seau ctIr
Address.O y AflawiS i,- Fj1d,, ft5 Street Address/State Road/Lot#(s)
Il!
{ City PP&S State PAZIP 1100141 196_1' 5)1eKiIYvU\` S6.,r•e 1-ore
Phone#(1 )1017-_'I l- E-Mail Subdivision {1114
Authorized Agent 1hrnn.c -F esv/"-uVICe "01@ S ,,tg11.cow City _ __ ZIP_t 3 . 1 _ __..
nCW IJEW IKPTA CI ES (As Phone# (__- ) River Basin •TIM ptyvi
Affected - i
❑OEA UHHF riIH OUBA fiN/A
AEC(s): Adj.Wtr. Body .6c.(\\� Csre e 1. )/man /unkn)
iiPWS:
ORW: yes /trio PNA 0 / no �-r�l�r� Closest Maj.Wtr.Body QYY1�)CO Z,tVer
Type of Project/Activity ebvi ltrK Ck fi 9 b i A f bc...410'IE.A L4'44, re kt....trn
(Scale: I )
Pier(dock)length _3�"
Fixed Platform(s)_ n i ' 1 t
Floating Platform(s)
Finger pier(s) IAr
��. �-"�`+.'�I III: N
Groin length _ , j i
number i f
( ulith Riprap length t Tv.. i , d
avg distance offshore 0.
j
- r
max distance offshore iJ' 6 fS y ( �tif ,
Basin,channel PI,id I (9. if •AI fit)
cubic yards _ l
Boat ramp t)
-- — I ►ASV . . ,
Boathouse/Boatlift `I `' � A- j ' i
Y
Beach Bulldozing_ CAA : PA ",, ,
Other NFL ' W,� /
,I,*
_ , ;
?Rod'
Shoreline Length { y tG,- a� L _1 r� atIii ' i l i
SAV: not sure yes a t , i�l ����! i
Moratorium: n/a yes V..o g Q Gwoft
I
Photos: yes ( j + j
Waiver Attached: es no . )1 I ,.
I
A building permit may be required by: £ea.rid (lowly See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction) 1 l `
Notes/Special Conditions [tr 1u 1c� u f Me'S nr 1h r: v 3% `�te$
L 'VA 1 t ----.I-Pr-l-v'' sk-t--° /e- 't2, 6p,,e,
Agen Prin Permit er's Printed Name
le.
Please read compliance statement on back of permit** ignatur
P Chk •*9po•"` yex,o 3d s, 1-. v 3,.)..74-4-2_4)1- 1
Application Fee(s) Check# Issuing Date Expiration Date

0 _\' AMA / DREDGE & FILL N° 77401 A Z C D
NERAL PERMIT Previous permit# WI
��-- Al.New Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued {,j/q
As authorized by the State of North Carolina, Department of Environmental Quality j 00
and the Coastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC - I
� (fit ales attached.
Applicant Name L�I New F-D''+l`ill A Ij,v Project Location: County �j•eQuh�r k'
Address aOol yy11 gjGyy)S �7 $lv i l'4 ri5 Street Address/State Road/Lot#(s)
in
i
City I l 1 S State ZIP 11()-11 1 I`f She KilrwI` S(b i s i_ar e
Phone#(1g'I ) 1pu. /2 o E-Mail Subdivision 14 JP
Authorized Agent it,rrvc -Dom r un4-4-.1_@ s...t4;1 co.,LA City a(1.4‘ ZIP 23895
Affected El CW ❑EW (4P L`7P TA ❑ES TS Phone# ( ) River Basin g 1 Pm?)
O OEA ❑HHF ElIH ❑UBA ❑N/A
AECs : Adj.Wtr. BodyV. �('i&-
C
( ) ❑ PWS. �/man /unkn)
ORW: yes /a PNA 0 / no 1'\tfk-4 Closest Maj.Wtr. Body Ram,- Ca Z^tve`
Type of Project/Activity Cbsei 54-i-.c CA- fi 9 b' J+ b U` c Cl€l 11 1.6;44., r2_[ t r'
(Scale: I y )
Pier(dock)length i
Fixed Platform(s) ! I b r i `
Floating Platform(s) .3 t�
Finger pier(s) ��
8 P O 1 —. `� �j���P' ' {
Groin length I I _ N I 1
, , ; ,number i - _ 1 .. .. _ I
` . Riprap length t
avg distance offshore 0. !
max distance offshore 0 I �! - ! sift6
Basin,channel I - - l 1
4r- I
cubic yards 1 i �•
IF
Boat ramp ! If
Boathouse/Boatlift -r- -- -- - '1.1
Beach Bulldozing __ .--- IIIE 1-1. - --, .
Other .. t� L 1— ;$ %►, _��r�r
7 !r. ■■■■ I • I �
I IIMIMMIPIP ■arniii • Q Ro?
..w
Shoreline Length - 76 ! ;V__iiii: [ * • •
SAV: not sureyes �7�n
TV '
•
Moratorium: n/a yes 3io -, I '
Photos: . t
yes �......_..........__
Waiver Attached: es no , : ! I I I I ! I I I
// 7 lV
A building permit may be required by: &eali��T (Ou I . See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction) ! \r
Notes/Special Conditions La+ I 5 t� ,�etfl -e' L gees
] f LI SPvc1-1
Agent or Applicant Printed Name Permit leer's Printed Name
:1_ A
Signature **Please read compliance statement on back of permit** Signture-
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
i1 Tar-Pamlico River Basin Buffer Rules Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-648 I) or the
Wilmington Regional Office(910-796-7215)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

3
❑CAMA / ❑DREDGE & FILL No 77401 A t C D
GENERAL PERMIT Previous permit# 11)4
— ❑New iiModification ❑Complete Reissue III Partial Reissue Date previous permit issued 41/4
As authorized by the State of North Carolina, Department of Environmental Quality -114 I l+Q�
and the Coastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC ` .
❑(ales attached.
Applicant Name L1Yrne TO lti a+) Project Location: County �&AA.)Ccr'c-
Address )U 0). ,A60,,rrI S '12+ 3)v ¢5 Street Address/State Road/Lot#(s)
City /7 g•S State PA ZIP I) C4 L j`t b. , fy it ti.1 y\rr4-‘ S ii,rt rare
Phone#(7.A ) &22 -(o/ZC) E-Mail Subdivision J 1 R i
Authorized Agent 14 n n•e 'C o U n ct rc 12 S.,, -. .1 • a City 1:27.cAl-k ZIP Z 480s
Affected ❑CW ❑EW IV/PTA ❑ES AS Phone# ( ) River Basin T")4 e. J PP-fr'i
AEC(s): Cl OEA Cl HHF Cl IH Cl UBA ❑WA Adj.Wtr. Body PJar (f ee`- n-aTlman /unkn)
❑ PWS:
•. Zr r Closest Maj.Wtr. Body tV- am1) (.0 e r„'..r
ORW: yes /.fo PNA � / no �a
Type of Project/Activity rhyl 5Aru Ck ..1- 9 J a 4- U i.11 k -)eG 0 w('Tt., e e ictArrN
('Sale: 4. j
Pier(dock)length '� ' JQ )
Fixed Platform(s) Mil jam} - •:=■ . —■111111
Floating Platform(s) I 1 �_ — ilE�E♦ �r',+_
Finger pier(s)
Groin length
number 1 ....... �_
ile
r i , i. __,:,:,
:,, ■e
1
Bulkheadl Riprap length — — 1
avg distance offshore 0. a
��■.— ■
max distance offshore 0� � rr ����— ��•U
Basin,channel hilISTPAMIII111111111111101=1111111E111111111RE0111111I NM -
cubic yards — 1 , I o_ �i mm�
Boat ramp - 01111—
Boathouse/Boatlift `` }
i_ 1<ea.1A -�
"
i 'Al VA V .•
Beach Bulldozing 1 I S — �■ T.
1 • ---
Other `� i•i�.� / r _
Shoreline Length 1 /C) ir ir� ( D I1 U U•�IN
SAV: not sure yes ® 4� _._..� �_ � __ —_ � ....._.__
�` ! 4 Z _
Moratorium: n/a yes �o �1 l '
Photos: yes i E 1 ,. ,..._ ; . ——
Waiver Attached: es no ! 11
A building permit may be required by: gea4.4,/ C ,64,75( . 1 See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction) / `
Notes/Special Conditions i,c'F 4 rylai.-�.\r'9' u)1 i-Yft$ •
a b%i
Agent or Applicant Printed Name PermitOfficer's Painted Name
,//' )( .
Signature **Please read compliance statement on back of permit** Signature
PJ CI'k ``yam. ,-;,� c .:,.. - ,AI) �.,/ -�/ 2 ') I
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar-Pamlico River Basin Buffer Rules Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-6481) or the
Wilmington Regional Office(910-796-7215)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-648 I
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

0❑CAMA/ ❑DREDGE & FILL $,'
ly 77401 A B C D
GENERAL PERMIT Previous permit# .
Y� ❑New IA Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality t
and the Coastal Resources Commission in an area of environmental concern pursuant to ISA NCAC !j . 110r.
riAules attached.
Applicant Name Li mete T c r 4:,.jr\X Project Location: County : •
Address a'.-2. f-i`„�.NIS t }jjvo { Street Address/State Road/Lot#(s)
yyyy��City I71 PRS State PA ZIP It( Li ' i`'1 ) f • .;'r < 'N; '- •;, _-_+,,,,•.,- ,
Phone# (1 4d ) tZZ - ./?C E-Mail Subdivision "J J A
Authorized Agent /-a,n,-,tf - , i , ,I' City '"' ,ct V\ ZIP i -isps
Affected ❑CW ❑EW E/ TA ❑ES ITS Phone# ( ) River Basin i h la. I ►P/i f
AEC(s): ❑OEA ❑HHF ❑IH ❑UBA ❑N/A Adj.Wtr. Body ''7-k\r':- C f'eV:- (nat /man /unkn)
❑ PWS:
��; Closest Maj.Wtr. Body -C7'-A,�'1 ' C,6 "'`'r
ORW: yes / no PNA (yes / no 1t r�
Type of Project/Activity t j„- S i, C) .: b .l i -.. , ; ��
( ale• 1 _sc )
Pier(dock)length
Fixed Platform(s) -1111 I
Floating Platform(s) ' '" 1 ' .
Finger pier(s) ""_ ti �i ] i I I — 4— .0-7414 , 7 I , iii.- i is—'.-
Groin length j 1' }
number �__. __.. .. . . . i .._ '
Bulkhead/Riprap length t -I -- -- T ...._.....__-._. _ ..-
iili
avg distance offshore Q.
Q. :..- i I I 1111
max distance offshore 4, 7 : , �' �' $
Basin,channel ,4t'' 1" - . 4/ 1 st3
f ,y1 I
cubic yards ' F /f
Boat ramp X
nr
Z'l
Boathouse/Boatlift
I
l +
W r .
Beach Bulldozing - --- -- I. �M,, ,_..
�t 1) t 1
Other ; _ �� qL 4-
i . : ! ,
• -} • I R
Shoreline Length t 0 I •" t, i 1r f R i I
, I i ,
SAV: not sure yes (r o _ ,y -- T.
Moratorium: n/a yes ,o
4V I ---- -i-- +fir- --- __� _�
.� ,.
Photos: yes CP i111 '_
lill
111
Waiver Attached: es no I }
A building permit may be required by: ` " ' („u 4 f/ ` ‹:note on back regarding River Basin rules.
(Note Local Planning Jurisdiction) 1,�
Notes/Special Conditions A•,o 4 nelp t s..\-+k ,,A v..)%1:-L, \'''x ec.5,
Agent or Applicant Printed Name PermitOfficer's Printed Name
Signature **Please read compliance statement on back of permit** Signature
I>d 0,k .'t/00.4- ) ;i
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin RulesApplicable To Your Project:
"tarPamlico River Basin Buffer Rules Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-6481) or the
Wilmington Regional Office(910-796-7215)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick,New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

I
,, ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
Coastal Management BRAXTON DAVIS
ENVIRONMENTAL QUALITY Director
BUFFER AUTHORIZATION CERTIFICATE
FOR PIER AND DOCKING FACILITIES ACCESS WAY
A riparian buffer authorization is required for pier and docking facilities access ways through the Tar-Pamlico &
Neuse River Riparian buffer per Division of Water Resources (DWR) regulations 15A NCAC 026.0233 & .0259. The
Division of Coastal Management(DCM), through a Memorandum of Understanding with the Division of Water
Resources (DWR) has reviewed your project proposal and has determined that the project as proposed complies
with the aforementioned regulations.
Those activities covered by your Coastal Area Management Act(CAMA) permit have received Buffer Authorization
provided the project is constructed in a manner that continues to meet all of the conditions listed below. Failure to
comply with this Buffer Authorization may subject the property owner and the party (contractor) performing the
construction and/or land clearing to a civil penalty by DWR of up to $25,000 per day per violation.
i. Crossing is Perpendicular: Pier and docking facility access way must cross the 50 ft. riparian buffer
perpendicularly (which is defined as between 75 and 105 degrees) unless otherwise approved by DCM.The
alignment shall minimize the removal of woody vegetation to the greatest extent practicable.
2. Pervious Materials: All reasonable measures shall be taken to ensure the access way is made of pervious
materials like open-slatted wood or composite, mulch, or grass to meet the intent of the rules to the
maximum extent practicable.
3. Access Width:The width of the pier or docking facility access way shall be limited to six (6) feet.
4. Project Drawing:The drawing on the CAMA General Permit is considered the project drawing of your
property indicating the relative location of the pier or docking facility and any requested access way. This
drawing will be used to aid in compliance and monitoring efforts.
• P /
-project site conditions: L 6� / 5 n'Iah--2�)i �d w`i, u/�-project
By your signature below you agree to be held responsible for meeting all of the conditions listed above and verify
that all information provided is complete and accurate.
Agent or Applicant Printed Name •ermmi•�icer's Siltaallp
9 '
Agent or Applicant Signature Issu- Date
CAMA GENERAL PERMIT#: 7-.7-41b1 5
State of North Carolina I Environmental Quality I Coastal Management
Washington Office 1943 Washington Square Mall Washington.NC 27889 1252-946-6481
Wilmington Office 1127 Cardinal Drive Ext.Wilmington,NC 28405-3845 1910-796-7215
Morehead City Office 1400 Commerce Avenue Morehead City,NC 28557 1252-808-2808

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
•
I hereby certify that I own property adjacent to \--\[ t -In‘'" vL0L 's
(Name of Property Owner)
property located at 1 y -1 ANOL,h cV1.6( L 6-An
(Address, Lot, Block, Road, etc.)
on '- 4 C.r-e -k.- , in --1)Gt`-Ph , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
12.5 rki I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
Ot S k f/► LgilD I �'-7 t o a- k.1. 1 „_,,eo✓ / a c
fr. I ,c-c.C��,.� p roI ', 1/
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15' from my area of riparian access unless waived by me. (If you
wish to waive the setback, you must initial the appropriate blank below.)
25 IN I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Inform ion
i�tuNt e Sisznature ',
'1'
Lynn Fflr�unAsla ?o h n Fi. . � c '! ► n 1, (L S, Ll L4-0
Print or Type Name Print or Type Name
/ve7 shfit') h. st-t �„�r �� /41& 9Se(CL,t,it- CafY(-e-__
Mailing Address a78o Mailing res
��,,, , /L a -7YaY 4 L toe- 2- gOe
City/State/Zip City/State/Zip
- 9yS-a7.2_0
Telephone Number Telephone Number
7/42 /L� 7/Z2
Date Date
+Ah't e Adult.55 (Revised 6/18/2012)
a�k3helizims R74,slut(-
/Yl 42.5; Pa-. /4,a L/

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to LInA. T S&hr\ ( c�.r�n,- s
I (Name of Property Owner)
property located at I.�v S he-4c \ S 1173+ t
(Address,
ck Address, Lot, BI , Ro`g�d, etc.)
on Cf C �-{� , in Gz.`t'h , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
Io�tiQn.
/0 I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing developmente must fill in description below or attach a site drawing)
OL6g t (Ls, pu T n c- t/Ic kea- t? v r ,�, (49 f ro f-
.c Skbrt rtr' e frape
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15' from my area of riparian access unless waived by me. (If you
wish to waive the setback, you must initial the appropriate blank below.)
nib I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
/t
gnu!' • SigM'c
u►•e
L nn �Dr -Cna. ohn �o nano c )-5.1 oScmit n
not or Type Name Print or Type Name
I ") Shde-itch 5ho I.So I Sh&kina..h ShA+ �_L4 ,,
Mailing ddress Mailing Address ^ )
ay-t, , 1UL �- WO '' /��` /v VoV
City/State/Zip City/State i
a �p
Telephone Number Telephone Number
Date Date
/ Date
at
o m e_ it dclre-5 S (Revised 6/18/2012)
aoa A-ckn s ff,BIVD
171.A4S, PA gaD el

ibeLopl pc44„,
Fo2 � rwda ek yCo9 Pokc"F
R/ro /ao�

Pic Divisions of Coastal Mgt. Habitat Impact Computar Sheoi
Applicant: L yMn E /�Y114
4-6
Date: 9-30-W
General Permit#- 7y1)I
Describe below the HABITAT disturbances for the application. All values should match he name,and units of measurement
found in your Habitat code sheet
TOTAL Sq. Ft FINAL Sq. Ft. i TOTAL Feet FINAL Feet •
I (Applied for. (AnticipatedFeal (Applied for. ,Anticipated anal
DISTURB TYPE Disturbance total disturbance. Disturbance disturbance.
Habitat Marne Choose One ncludes any Excludes ry total includes I Excludes any
anticipated restoration any anticipated -restoration and/or
restoration or and/or'erne restoration or temp impact
emo impacts) impact wait) temp impacts) amount)
a
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