87363C - White, Julian & Brooks, Michael

o1*01(OAR41 ❑CAMA El DREDGE & FILL N . 87363 A B ,` o
G E N E RAL PERMIT Previous permit
Date previous permit issued
❑ New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
15A NCAC '. ' ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name 6 Authorized Agent
Address --- - Project Location (County):
City State ZIP �: 'x - ` .! �;J Street Address/State Road/Lot #(s)
Phone # ( )
Email Subdivision
City ZIP
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
(Scale: )�! )
Shoreline Length
Access Length
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Total Platform area ?k
Groin length/#
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/Sill
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
SAV observed: yes no
Moratorium: n/a yes no
Site Photos: yes no
Riparian Waiver Attached: yes no
A building permit/zoning permit may be required by:
Permit Conditions
i
r 4FZ
I I`_ .l_.,...
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
(Please Initial)
Signature "Please read compliance statement on back of permit" Signature
Application Fee(s) Check #/Money Order Issuing Date Expiration Date

`OASNI ❑CAMA ❑ DREDGE & FILL N9 87363 A B fc D
2 ti2 GENERAL PERMIT Previous permit
Date previous permit issued
❑ New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
15A NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name Authorized Agent
Address Project Location (County):
City State ZIP Street Address/State Road/Lot #(s)
Phone # ( )
Email Subdivision
City —ZIP
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
Shoreline L
Access Len
Pier (dock)
Fixed Platfc
Floating PI<
Finger pier
Total Platfo
Groin lengt
Bulkhead/
Avg distanc
Breakwatei
Max distan
Basin, char
Cubic yard!
Boat ramp
Boathouse,
Beach Bulk
Other
SAV obsery
Moratoriur
Site Photos
Riparian W
A building permit/zoning permit may be required by:
Permit Conditions
nat/man/unk)
(Scale: )
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
Agent or Applicant PRINTED Name
Permit Officer's PRINTED Name
Signature **Please read compliance statement on back of permit** Signature
Application Fee(s) Check #/Money Order Issuing Date
Expiration Date

Styrony Heather M.
From: [e-mail]
Sent: Tuesday, April 26, 2022 7:21 PM
To: Styron, Heather M.
Subject: [External] Needed permit 211 Gibbs Court Beaufort
Attachments: Doc 04-26-2022 19-17-56.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to Report Spam.<maiIto: report. spanvL&i _,g
Hey Heather,
Need another permit. I have attached everything. The proposed work is going to be over the property. The neighbor
waived the setback because they actually share the dock and the finger dock and lift is for him. Please let me know if you
need anything else.
Thanks
Andre
252-665-4378
Sent from my Whone

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
'n Permit: � l l t' Y\ C" t � j c 0 �B Yy� k,
Name of Property Owner Requesting ,
klailing Address:
Phone Number:
Email Address:
-2, 11 G ► �4s �Ouv' A
21-L- 7 4 1 - q $1 �
6 V 00 IkSVV-- S Z� T v\Aa, I - C. a
I certify that I have authorized YR �v P.6 6
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: �7
oA► C f/- ► �'� O
L i P T N,a ' )Nan. oyaje
at mYproperty located at -111 G - b b � Cv Lr T f e a, 4 `
in C fxv t k.,f 9-)( County.
l furthermore certify that 1 am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
A A _ _ j &-:14 t& t,,�
Signature
Print or Type Name
W tNe.r
Title
4
Date
This certification is valid through 0 4 /_, 7,0 _l

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIEDILRETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner:
Address of Property:
Mailing Address of Owner:
Scott Brooks
211 Gibbs Ct Beaufort NC 28516
211 Gibbs Ct Beaufort NC 28516
Owner's email: brookssms(M-hotmail.com Owner's Phone#:
Agent's Name:
Agent's Email:
Andre Webb
[e-mail]
252-241-9828
Agent Phone#:
252-665-4378
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
permit has described to me, as shown on the attached drawing, the development they are proposing. A
description or drawing, with dimensions, must be provided with this letter.
XI DO NOT have objections to this proposal_ I DO have objections to this proposal.
If you have objections to what is being proposed, you must notify the N.C. won of Coastal
Management (DCAO) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 400 Commerce Ave., Morehead City, MC 28557. DCMrepresentativves can also be contacted
at [phone]. No response is considered the same as no objecdon if you have been notified by
Certified Mail.
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, rift, or
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.) A
I DO wish to waive some/all of the 15' setba
SignWtaq of Acfacent Riparian Property Owner
-OR-
I do not wish to waive the 15' setback requirement {initia) the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO:
tTu[z Wh-!Tv.
Mailing Address of ARPO.
ARPO's email:��Ci Qt .CAS ARPO's Phone#:
Date: q''�z'"2 ?� *waiver is valid for up to one year from ARPO's Signature*
Revised May 2021

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER (NOTIFICATIONMAMM FORM
CERTIFIED MAIL - RETURN RECFJPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner:
3-40 T 34,4>14f
Address of Property: Z// G lfS Yr c of f / f���a¢, NC Z8 5'16
Mairmg Address of Owner.
5"000V
Owner's email:
4e-d01<Y5,W.F % •�� !• dwOwner's Phone*: Z .5- 2 -
� IN-.1m4eA l:Agents Name. �gent Phone
Agent's Email: `'"``���� iOi''i' ti, rl • �rj•
ADJACENT RIPARIAN PRO MSS CNWM R'S CERTIFICATION
(t3ottorrn portion to be coby the Adiawent Property tlwne+r3
I hereby certify that I own property adjaceritto the above referenced property. The individual applying for this
pemd has described to me, as shown on the attached drawing, the development they are proposing. A
descriotion or drowana[- with dimensions_ rrbe nravided wih this
Mter-
V- I DO NOT have ob ; ions to this proposal. I DO have objections to this proposal,
if you have objections to what 1s -- being Pr�e- C(, You must notify the N.G. DhFision of Coastal
Mara titmi (DC" in ding wit 10 days of mceipt of this notice. Caffeq ndence shored be
nmftdio 400 CkwunerceAve-, Marehead Cft NC 1. DCU s crn afro tie c led
at (254 868-2W& No i esponse is sidw+ectthe same as no objection Wyou hwe been na oW by
Cer~ Ab&
WAIVER SECTION
I understand that any proposed pier, clock, mooring , boat rwR, breakwater, boathouse, lilt, or
groin must be set back a mmimaun ice of 15' Imm nq area of ripai m access w*w waived by me
(this does not apply to bu*lieads or ripraap revelments)- (if you wish to waive the setback, you must sion
the appropriate blank below.)
I DO wish to waive somelali of the 15' setback
-OR-
Siar�ofa ftarian F'lWerty Barer
I do not wish to waive the 15' sec ret; --ne It (initial the blank) - P=
Signature of Adjacent Riparian Property Owner.
Typed/Printed name of ARPO: -N- PL-Va,-..
Mailing Address of ARPo: 3 Ss
ARP(Ys email: 3nt�lQ-e*. ARPO's Phornelk O t cow � (Q
Date- •waiver is valid for up to one year fmm ARPO's Signature*
Revised May 2021

v -

NORTH CAROU-NA, CARTERET COUNTY
i his instrument and this certificate are duly filed at
tha date and time and in the Book and Page shown
,x) the first page hereof.
J'S
BY,erry� -.-I T_ Hardesty, R- gi.-egister of Deeds
&&
AW. aewcy. Reg► w of Deeds
FOR REGISTRRTION REGISTER OF DEEDS
Jerry T Hardesty
Carteret County NC
t November, 04 201511 8 43 AM
vMARY AGMT $ p
C?R i'I { C',��1�.(:)I.l'N.a Fey $zs o©
��:�I�TCIzr����. CO l.'NT�' FILE # 1E24401
lam:1.71EiI IEN ! AND ,ir_�Ii�'11' LTSFa AGKEi .lIFNT
THIS FASFMf--'1NT AND ,JOINT [_*SE ACiRFI-:MI`.N-f' is niticle ar1(I elltere(1 into
oil tills 111 7 t clay cif\ No cnihcv, '()I 11V jtllci l)et\%-e.•11 :fej-�llcliltc (1. E3rc oks
�Brooks") of Carteret CoLIWV, alid .{tlIkIll J. WIllte cln(l \Vlt+r. 1 leiltllej- S. ` il[te (Ile, -till
"White") (.)t,1'itt CCllllltj!, f()1- tlIC f')L1FI)W1 C, Mid C011sider;itlons wet I-ot-tll bdo\v.
WH FAFAS, t3rooks and �- llite boil] of ll resi(tellhi-11 pl-operties adjoining each
other along the shorelille ol'Gibbs C.'reck, l31-ooks'' lilt hrrill� Lot Q, Gibbs Court, lic�mii'lrt,
NC, mid White's lot hetllt; I.ut S (fih1)s C`(lLtrt, I3(:au i.lrt, NC: and.
WWII-R AS, l:l certain (lock, \vZIS III-C 10LISiy' COINrt)rted by 131-00{:s ilncl t111° l�riur
oNvner of Lot 8 at the the Ct)lllllloll bcqllltlarV 1111l' ()f, tilt: I}tlltic's_
Whi Ch (IOC< is +`011ftglll-e(l its a "T" with all OLIt1-barcl floating 1)liltli)1-111, all(] heing
appl-oxiniately 125 t(;c:t ill len tll; tilt; -I— {lilt-t tilt tilt. (',11cl ht'illg 1pl)roxllll,ltelV {2 f`CUt hy
10 feet; '111d the plritlltlry i-1.111 of the Clock heill-g approximately 5 feet in \ti icltll. the
(eiitel'Illlt' t11Cr�°cif l�t'I , tilt' approximate C►Lttt1'di'd stl'Ell<vllt 1111C extellsioll of, the comillon
huLill lLlr-Y line (lf the {parties (het-cl 1 ' Dock")- "llld
1�'G'1I Rl f'1S, Brooks itlstalle(l - ho�lt lift on the right side of the "I" part o!' tilt
Dock, tihc c;lec:ti-Ic i oc vulr liar said ho'It lil-t heing 1)md 1'or by Rrooks; however, there is
currently no boat lift on th(2 left side, and,
PAGE

A-1IFJZ1LAS, a sketch oC this Dock- �wd its at�I�rc�xhilaw 11)Catioll to the C011lll,le)11
butlnclary line; hCt«r'erl tllC t«c) l_(_)ts c)t- tile 1l�lrticS i; ,itt�tched hereto) ,IS i~xhihit :1 Owt
drawn to S(:LI1C), atici,
\VI11-IRIS, s. zltt�lchcd 11erc;to �ls Fx1lihit 11 dre two phot[1praph ol, the
re°spe[ tine i.c)t5 clt) tlle 1laI•tI _ -S iiC1 Lo)t�; hCIJ c)tltlilled i11 111LIC, and Cil)iCtill- th
approximate lc)catioll ot' the Dc�CI:: and.
�-V[ IERF. AS. the pal -ties desire to SCCure to themselves, their heirs, wt1CCCSsors and
a 5i n the CmItinui11" Inwi't11 rig-111t tO jc)illtlY a C� M-lCi �h�I -e the l.D)+;i`: ill tile: hlttll'c° "lnel to
-Shnre the reasonable expt nscs incident to the repair and lllaintc1lance thel-cot'l and 101" this
i�l.11'11[1tiC' CIO exC'C Ute', this rig.t-t't;ment.
NOW. 411 RL:FORF, t'Or and i11 co nsider-Lttioll c)i•thc tllutual Co' anent., bCl1e Itti.
tcrills and conditions which t6110 w'. ttll of which the parties eleern to he; valuable
reciprocal conslderatlC)il to sllllport this Agiccinent. tll[ l�<1rtiLs �1L1'E l'• �lti tt)llc��Vti:
l . I-ach party (.Joe lle;l'e:hy t?:irL.�llII, UT�Illt, �111e1 C0II� C N-! UtltO the other party a
110[1-0,CILI ilve, p rp tual e�lscmellt allci use ri-llt 101- L1i:1lc;rtl] j1edC$triarl MId utilities aICCCSS
l)url)05e,S to the Dock over and upon that area Cif their l..c)ts WhiCh is l (.) fCet 11y l t) i-'Cet,
and I0Catecl ttl tire' Corner c)i r�ach Lot at the point wher[: the (lock is first attached to tile:
Lofts ut the sllordiile. Sj)CCI11CLl1k. the l () x 1) arc�l oil Rrc ok,-,' 1,()t is ill tite Southeast
C[)1'11C1' 01 that Lot; and the 1 t) x 1 {) area ()II WIlite's Lot is it) the S011t11tVe;tit C0 1-l1C'I- of that
Lot, To lwvc rind to hold S,11CI C �IseI11e11C tC� the lt5t a11C1 I)�nttlt of eziCh e)t11C1', t!lelr 11C1I'ti,
successors, and i1SSIUI1S 111 l)C.11)c'tt1111', l)ttl"Wililt t0 the: tel-IIIS Mld COI S Set }i)1'lll
hereill,
E
BOOK PAG_,

�. I.�lt 11 tl'1lty }1;�1� Ise c �ll!�Ili\ lt;thl�: ;,1r all 1't:;t 1111ilb1t' COLS 5 aticl c:r1vll�;c'ti
I'C1ISOIIid)I\' 11eC(2SS,I1-V III firth:✓ to) lief"� i Il'�l??lt:t'►1 [lit' l)�����. It`, l#�'t'}� 1'�i1ilFtl'�. IIiC� It
5lthll(11_tlll`.' 1111'11�;s �itlll Stl'11CILIE,11 t11e1111-ei'`. i!i :1 `=itit' 1f11ti llllt�'t►ili]lll.; t:�ll�.11lit111. iitlll lit ltli'
tlleil- illtenlit-d 1')LII-I) )SCS. 1"he"l [1rt11'�tiii.i}i� ;1J;11I :i}�;�� �' �1 Cil th;}i.li.�ll 11114 1111It\ llJJltln�llltlt'J
Usc of thc: Dock. or cli l:lllillls im% rl,-..11t (A W Q' 111111 tl7t (ilfltic'� l:f.l t.0 tl i It a f•�'�'ll-
nlitilltainecl l OCk <lddStct t►lc I1lal-kct llili
eit►lc r Lot owner uses the Silttle.
j, No e\Ccllsions 01- ll(llltttl117� t0 tilt; Deck shl dl be I1lac4 \�ltht�llt the !lli_iIil�.11
consent of the pililleti, Subject however U.)litl°'' �lI1iI�1tC'I ! riy_'lit to'ill�t ill Li ht�ilt lift c rl
the Icjt stile cat` the dock and a ;ink lit the "Jv`h cleal}ill�A Q130011. In the eN ellt While
clesil-es tt) Ilc1tit lift On tlic Dock. install -Alan and Inimitell;llicc k2spoll"t
SLICIl Ilcl�lt lift SIIAI Inc ')01e1�' ".1tl7 wellite. ;md I3rw)k� <I-wlI ll� %'c !7<.� rt SI�t�17 ihilitv lty �n.tre
111 1111V 1Ctllllrt'(1 t.'llitti li}l' hell 111,ti11I��?1i I?, l[ILlllltl'ikl!l�t', t�1' `,iIIIIC`' t\lll';1 e. I'Ll1't►lt't'.. li
White itlstall5 <1 boat lift. then \'17;t1: lltt>l Inc re�;ru.+nil)ic to properl\ ;-oli net the electric
p()1.' er f6r sa�ll heat lift tc1 their own z'leett1 nit tc!'. and be 'smel`� rc Ilonsil�l� to I}.1�' ft�l"
tii-llllC.
4. No thl!l" "Imll llrc Lilt Cithe, party frot7l rQ11ttiq; tlll.'lr hon-les it) third jmlr \'
renters find �JSSHTIII11v tlSC 11) ;lac Dock to such tl'n.11ltti lll!rlsuJI. tentll7(;1'. Neither
pj11'tynor an 1)enlllttCe c1l a l)mly. shall Ili. c use o till' Dock 1111 illll' t:llinmerc al
vclltures'. Se"It"Ood lanclli LIS. 11100r111t.'.� (d third p lrt\ "t s`t:14. oi- for rciltal purposes (other
than renters of tilt' homes of the parties) N't) vCSSCI �h':ill he 111001-CLI 3t thc; I3()Cl\ fllr
l}urPOSCS cal li\ ill oil boal-d thc Vessel. '\t, iisl' t ltanil;rt statiollti, t'tcck storage Mixes. 01
BOOK PAGi:

c�thcr s11t h �nh,ltlL(:n1� 11t� (� �lll�lill�_ �.\ls(ill4' cii11micclllt'.ilts) Shull he construc le(f (111 the
Dock wil1w)ut the C:(,ilscilt (411()t1.1 Pill -ties.
1. l lle l)al-t1CS 11MV 111sL11'C the f.)(Ic1,. itu) ililtil �asu111ty dall1i1L, hut olllV' with
the 111utua1 COIAsCtlt 01' 1)(1111 to 1)�1\ the N(11,11I-ed l-M-C-111iuli1, further. each Lot owncr h('111
liltly 11r��1111sts 11 lhilltl' III sllrllll't' (��'ilh llllllt� llt 1{1t?.{.}()(j (j{} 1)cl' OC;1.:l1{FC1*1�C) t(iVC�ill
1)ers(zi1a1 injllrV arlcl 1)1-01)crtV clanluj�,e \NA1iCh ()CC111- tO anti 11�111V or 1>Crs(�rl ClItitIC(I W
t11c LISC 01' said DL)Ck_, i111(1 Whic11 is it prouinate il'.id f0resecuble Coll Sequence of the use
thereof. Upon request of either 1.()t 1)I-00f (,f' suLh stlall I)e (ielrli,rl�tratc (.1.
C ovcra c: (:)t, tills li(lhility is acccptahle it' provided as a specified. additionally 11rotec:ted
stpre11115es" o the o m1 rs} prlllml"V hoilm.1wller S illstirant'e 1)()11Cy l'(�VCl-111U ISUCII 111111II1tV.
6. 1 his a"reell'lellt and easement shall 111L11-C to the benefit of the parties, thcir
11cit s, sll��tssc�rs. �11)d assikils, Mid shall lass to Lail title successOrs as at1 Elf)PL111C 111nt
benefit to both Lots. whether Inctlllolled ill) 1111V C.'MltCV' lllt'l' illslCuliltllt W' 110t.
1. fills Agrccaient shall be rccL)rdcd
upt)n the
public recto tls
of' Carteret
C'uunty �lll(1 shidl he hillclill_; ul_)()n �111 ,(.lcc.e5s0rs
it1 title to
the
the
parties.
W11LR1-:1"uRtZ _the 1)'Lirlic:s ex"-'eutr tills 11IS11-L1111cllt 1i11- lhoi purposes SO (Ortll Here:
111t(:11�1in the Shill(: to be efFCL:tivc f�rolll and after the date tir>t t1111�( liriil- ttl?(��'c
Julian 1. White - - — - - Heather S. While
jenuldine It.
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STA L ()I` NC)RT1-1 CA
L the Ulldel'Sloncd Notary PUNK of the Comm:and State tlet'I'tik' that
Jull"an .1. \k1lite and wire. Heather S. \'Hite persolially appeal-cd hCforc; I11C this day and
aICIWOWICLI()Cd the CXe L111011 Ofthe lc�rL'L't11lls� 1115lrLilllent.
Witness Ill\' hand and oftic ial `eal• this y-' (Ulv of \—ovember- '20t5.
Notary PLI1111C (5I"11 1111(1 I)I-filt I-M1110
C'Ot_;NTY ()F CAI,-I_CRI+T
1_ the undersigned Notary- PUNK Of the Cep IMN? alld State al'01TS li(i, CCI-tilt' 111"1t
Jeraldine 11. Brooks personall\' alll)c:etr��j1 1)i t')re I11c: this dad' and �lc:knc►tided )Cd Lhc:
CXeCLItI011 Oft11e f(IN(l(7ing inStrlllllt'11t.
I
Witness Illy Imild and oll-1cl Il scull. tilts � � � do ol'NtrvembcJr, 2(l l -5.
Notary Public (`loll and 11, Ilt name)
IV1� ct�n�rnl'loll expire"..
4•..
ilI Deeds deck.sIiijriji�-'...ILrcc•mcjII.htv(.)k.�,\Nlzitc.�.doc
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!

A A1*.LrtSJ[%jLtU-N rKUjr�Kj'Y ()WNM STATEM[ENT
(FOR A PIEKIMOORIIVG GSIBO 7LIPTIBOATHOUSE)
-jLI hereby certify that I S
(game of Property Owner)
T _j,; �,t r
property located at
(Ut, Block, Road, etc.)
in
on N.C.
(Witterbody) (TowuFAkn-c Wr County)
He has described to me, as shown below, the development he is propcsing at that
location, and, I have no objections to his proposal. I understand that a pier mooring
pdings/boatliftfboathouse must be set back a n =*'Mum distance of fifteen feet (15') from my area
of riparian access unless waived by me.
I do nOt wish to waive the setback requirement.
IAQ wish to waive that setback requirement.
DF-SCREMON AND/OR DRAWING OF PROPOSED D1EVFX0PM1ENT-.
(To be filled in by individual proposing development)
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XN
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -------------__----------_---a-_-------- - - - - - - - -
Signature
Print or Type Name
Telephone Number
Date:

vrco,�u r-ree Ln-oo Hgclresses. " deb based and secure Email - mail.com
-F -6 !
O 1
N�.
This :n1ap is not a certiCed survey
and has not been revicwed by a iocal
iclovernment agency for compliance
with any applicable land development
rceulations
BOOK PAGE

r, ce r=mum HuureSses: vveo oasea ana secure tmaii - mail.com
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