NH_17-13_Cook

Chris O'Keefe
Planning & Inspections
Director
May 17, 2017
Jerry Cook
8604 Bald Eagle Lane
Wilmington, NC 28411
NEW HANOVER COUNTY
PLANNING & LAND USE
230 GOVERNMENT CENTER DRIVE, SUITE 110
WILMINGTON, NORTH CAROLINA 28403
TELEPHONE [phone]I18
FAX [phone]
Ken Vafier
Planning & Zoning
Manager
Exemption Number - E17-13
RE: EXEMPTED PROJECT- SINGLE FAMILY RESIDENCES WITHIN THE
ORW ESTUARINE SHORELINE AREA OF ENVIRONMENTAL
CONCERN (15A NCAC 07K .0208)
PROJECT LOCATION/ADDRESS - 8604 Bald Eagle Lane
Dear Mr. Cook:
I have reviewed the information submitted to this office in your inquiry conceming
the necessary filing of an application for a minor development permit under the
Coastal Area Management Act. After making a site inspection on May 3, 2017, 1
have determined that the activity you propose is exempt from needing a minor
development permit as long as it remains consistent with your site drawing
submitted on May 2, 2017and it also meets the conditions specified below. If you
plans should change and your project will no longer meet these conditions, please
contact me before proceeding.
SINGLE FAMILY RESIDENCES WITHIN THE ESTUARINE SHORELINE AREA
OF ENVIRONMENTAL CONCERN EXEMPTED
1. All development shall be located at least 40 feet of the mean high
water mark or normal water level from waters classified as ORW.
2. No ground disturbance or land disturbing activity shall occur within
40 feet of the mean high water mark or normal water level from
waters classified as ORW
RECEIVED
DCM WILMINGTON, NC
MAY 1 7 2017

The development may not exceed a 25% built upon area within 575
feet of the mean high water mark or normal water level of waters
classified as ORW, and shall not include any stormwater collection
system.
The development shall be consistent with all other applicable CAMA
permit standards, North Carolina Building Code standards, local
ordinances and local land use plans in effect at the time the
exemption is granted.
This exemption to CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal or Local authorization. This exemption
expires one (1) year from the date of the letter.
Sincerely,
Christine R. Bouffard, LP l
New Hanover County
230 Government Center Dr.
Wilmington, NC 28403
Cc: Courtney Spears
ECCIVED
DCM WILMINGTON, NC
MAY 1 7 2017

Locality
k;JPertnttNumber
Ocan Hazard E 5 6.inne Shoreline: ""f ORW Shoreline Public Trust Shoreline_„_ Other
(For offzcwI use onlY)
GENERAL INFORMATION
LAND OWNER
Name
Address / • (�I/
City4/416 ( li k t 91#V0-State
ox. rv+t�tytw E7s✓ N � an.
AUTHORIZED AGENT
Address
City
State
of /r �r17ou
is ;3 /X�
�c-,41, j�
Zip2gf- G Phone 73q
2ef- it
Zip Phone
860¢ /�lL�i C/f�Lr i rk: t wtr✓Yllri�br7v� n L✓
LOCATION OF PROJECT: (Address, street name and/or directions to site. If not oceanfront, what is the name of the
adjacent waterbody.) 4-lif7�vrjt�
DESCRIPTION OF PROJECT: (List all proposed construction and land disturbance.)
SIZE OF LOT/PARCEL: 23 sue' square feet ' S� acres
PROPOSED USE: Residential)j (Single-family Multi -family 0) Commercial/Industrial Other
COMPLETE EITHER (1) OR (2) BELOW (Contact your Local Permit Officer ifyou are not sure which AEC applies
to your property):
(1) OCEAN HAZARD AECs: TOTAL FLOOR AREA OF PROPOSED STRUCTURE: square feet (includes
air conditioned living space, parking elevated above ground level, non -conditioned space elevated above ground level but
excluding non -load -bearing attic space)
(2) COASTAL SHORELINE AECs: SIZE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR BUILT
UPON SURFACES: 1400 square feet (includes the area of the roof/drip line of all buildings, driveways, covered decks,
concrete or masonry patios, etc. that are within the applicable AEC. Attach your calculations with the project drawing.)
STATE STORMWATER MANAGEMENT PERMIT: Is the project located in an area subject to a State Stormwater
Management Permit issued by the NC Division of Water Quality?
YES NO ✓
If yes, list the total built upon area'impervious surface allowed for your lot or parcel: square feet.
OTHER PERMITS MAY BE REQUIRED: The activity you are planning may require permits other than the CAMA
minor development permit, including, but not limited to: Drinking Water Well, Septic Tank (or other sanitary waste
treatment system), Building, Electrical, Plumbing, Heating and Air Conditioning, Insulation and Energy Conservation, FIA
Certification, Sand Dune, Sediment Control, Subdivision Approval, Mobile Home Park Approval, Highway Connection, and
others. Check with your Local Permit Officer for more information.
STATEMENT OF OWNERSHIP:
I, the undersigned, an applicant for a CAMA minor development permit, being either the owner of property in an AEC or a
person authorized to act as an agent for purposes of applying for a CAMA minor development permit, certify that the person
listed as landowner on this application has a significant interest in the real property described therein. This interest can be
described as: (check one)
an owner or record title, Title is vested ilvtl f3 F' Il�./}r21t. Y+% S, t D OX, see Deed Book `� 15 ' 6C �
page in they w e i? ;-y'L-r County Registry of Deeds.
W 6 - Z2,4
_an owner by virtue of inheritance. Applicant is an heir to the estate of T2F.�"FTyD
probate was in County.
_if other interest, such as written contract or lease, explain below or use a separate sheet & attach to Wappli-AW
NOTIFICATION OF ADJACENT PROPERTY OWNERS: NEW HANOVER COUNTY
I furthermore certify that the following persons are owners of properties adjoining this property. 1 of WkJiCHAt?JJ�4NG
ACTUAL NOTICE to each of them concerning my intent to develop this property and to apply for a CAMA permit.
(Name) (Address)
(1)
(2)
(3)
(4)
ACKNOWLEDGEMENTS:
1, the undersigned, acknowledge that the land owner is aware that the proposed development is planned for an area which
may be susceptible to erosion and/or flooding. I acknowledge that the Local Permit Officer has explained to me the particu-
lar hazard problems associated with this lot. This explanation was accompanied by recommendations conceming stabiliza-
tion and floodproofing techniques.
I furthermore certify that I 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.
This the �2 fL4 day ofth,)T� 20 117
Landowner or ppeCA rruthor�zed to act as his/her agent for purpose of filing a CAMA permit application
This application includes: general information (this form), a site drawing as described on the back of this application, the
ownership statement, the Ocean HazardAECNotice where necessary, a cheekfor $100.00 madepayable to the locality, and
any information as may be provided orally by the applicant. The details of the application as described by these sources are m
incorporated without reference in any permit which may be issued. Deviation from these details will constitute a violation of,
any permit Arty person developing in an AEC without permit is subject to civil, criminal and administrative action.

9--�3
SURVEY A%7AWWCX
LOT 37, 94P BOOK 5 AT PAGE 23,
SECTION 8. PORTERS NECK PLANTATION
PAR/D: R03805-005-014-000
NEW HANOVER COUNTY REGISTRY
2
— — — — 'rip
NOTES
LAMM.
1. A PORTION OF THIS PROPERTY DOES LIE Wn7#N
A FLOOD HAZARD ZONE AS SHOWN ON AMP AND
o IF (EXf57Af(.' IRON PIPE)
PER FFMA FIRM PANEL 3720 3270 00 K,
ZONES X VE (EL 14) d VE (EL 17).
a ERRS (DOTING RA&RaW SPACE)
DATED FERLNRY 16, 2007.
M1C (00STING U40. ME)
2. CORNERS ARE MARKED AS NOTED ON MAP.
EPK (DIISTM p/K� 'J
J. ALL BEARINGS ARE AM4 NETICWON NORTH (APR/L
PROPERTY
R/Y CME
4. ALL DISTANCES ARE HORIZONTAL FIELD A/EASUREMENIS.
UREA)
��� — PROPERTY LIME NOT SURVEYED
5. AREA COMPUTED BY THE COORD007E METHOD.
— — — — NON -SURVEYED LOW
1, Daniel H. Thompson, PLS, certify that this plat was drawn under my supervision from an
actual PnAd survey made under my sups sion from information as noted hereon, that
the boundaries not surveyed are c%orly kjk'0ated as dashed lines; that the ratio
of precision as cokuated is 1:10,000+ and is correct to the best of my knowledge
and belief. W4'tness my originol Signature,
License Number and Seal
this day of
AD, 2017.
a fi 11 �
tt �
SQ 'Fi+
Daniel H. Thompson, PLS
NC License No. L-2174
Zg0
A� a
��bD' 23.5��
• pp(X�rp.lr�'oP1ts� 2ban
S�4 s�f
SD tAV S uAX=O_Wl" S I S 4'
• V*w ftov + ov 144,
2-4 S_
r ►V11�JG OT? 1 �UU
daT�
Svc °
i L 91164
SQL
M tq FLOOD LINES SGr PC TAKEN FROM
�n,�r��/ y, , FEW MAP No.
e t/`i'. V •• K4l'�G Pf� V A,,e = 'i Sri S� C"� DATED 2/�/07
MAP OF SURVEY
FOR
JERRY A. COOK
OF PROPERTY LOCATED AT 8604 BALD EAGLE LANE, WILMINGTON NC
HARNETT TOWNSHIP - NEW HANOVER COUNTY - NORTH CAROLINA
SCALE. • 1 " = 30' APRIL 2017
n
VICWrY MAP (N.T..S)
MAY - 3 2017
IEW HANOVER
PLANNING 8 i
TOPSAIL
SOUND
(G f PA
1pa
towV-
LI(AAF
I
J M WILMINGTON.
MAY 0 2 2017
NC
DANIEL H. THOMPSON. PLS
THOMPSON SURVEYING CO., PA.
209 S. WALKER STREET
BURGAW, NC 28425
[phone]
avan a MOWPSaN, PLS
NC LM.ENSE No. L-2174
nRN No. C-am
_. FAE NEK—COCK

r /-71'35i
SEWVZY RBPA INM
LOT 37, ANP BOOK 5 AT PACE 23,
SEC'WN d PORTERS NECK PLANTARON
PAM. R03805-005-014-000
NEW ALANOKR COUNTY REGWW
VOTES- z
LArm:
]. A PORNLM THIS PAOPERIY OO6 UE
AZ
A FLOOD HAURD ZONE AS SNOWN ON l/AP
PER FERN FMM PANEL J720 3270 (b K. Z
ZONES X. L£ (EL14) d VE 17, W O
t�
o EM (IX/SONG APLM PIPE)
ER/i5 (0RVLa0A0 SPIKE)
(Ei
MAG (IX/SRNG ANG' MCC)
DATED FERRIdRY 16, 20p1. \ H
2. CORNERS ARE ANRNt�N07ED /
N
EPK CEX61xvG 7/K' nWL)
ON NAP (7
CS
J. ALL BFARMCS ARE MA NORM (APRtt ).
PROPERTY Lw
4. ALL DISTANCE ARE ONTAL FlTE NE451
___ PROPERTY LAVE NOT SUR4EYE0
5. AREA COMPUTED 8Y THE COOROMAfE MEINOO. �
�
— — — — NON_ SURVEYED LME
- _ _ _ - _. BP
� I
E'CM
WERE FENCE
5 50-24'08'E 296.58' TOTAL
CR455 24G56' WOODEN WALL BRICK £CAAusT 33.45'
WALL
4
/
GARAGE
2-STORY
MIsoNRY
I
v
g
2�45604 SF
0.541 AC ! CONC t
DANE
(BLOCK)
ORAL
i PIER y 5a[�iNAOL
�v
l`jyy
GRASS
b
LDw
GRASS PIA
E
.S(ATEI� \ w
STEPS 1
&
N 5O'JT'O2'W 298.7O'
WOOD WALL BRICK WALL t '� EIP
a#
\
\ DAMES MACKER vi POINT UNDER
POINT UNDER LOT J6 E06E 9f
BEDGE OF
RICK P MB 5, PG 13 BR1IX PILLOW
FLOOD LINES
TAKEN FROM
FEAM AMP No.
5720327000K.
1, Daniel H. Thompson, PLS. certify that Ums Pat was Mann under my supervision Nwn an DATED 2116107
actual Sea survey made under my supsrv�sIan from information as noted hereon; that
the boundaries nut surveyC/ surveyed am w k avlmd as dashed 6r that Me ratio
of omcision as eokuktee is I: 10.000+ one is corrcet to the beat of my knowkd9e MAP OF SURVEY
and bsiief. Mess MY ortpiA' I ST9notdm, license Seal Number and Se
this day af.•�' ,y2017 FOR
s JERRY A. COOK
Daniel . Thompson. ^ S
NC License Na. L- 74; D OF PROPERTY LOCATED AT 8604 BALD EAGLE LANE, WILMINGTON NC
HARNETT' -,O*NSNIP - NEW HANOVER COUNTY - NORTH CAROLINA oPSOi H. MONPSON CO.,PLS
iHOMP09 SAALKV? S o., P.A.
SCALE 7 " = 30" APRIL 2017 2os S. WALKER sTR£ET
BURGAW, NC 28425
,� 0 90 [phone]
aM4T1 N. RkJAMSlIV. PLS
KPWQQQME hL UY W, L-2774
lllal . C-MK,3
GRAPEUC SCALE - FEET Axc NEX-coar

suilwr Rillnu LM.B:
LOT 37, MIP BOOK 5 AT PACE 23,
SECTION 8. PIMTER'S NECK PLWA1
PARIO: R03805-005-014-000
NEW RANOVER COUNIY REGISTRY
_-----.�E7P
T
�
W
s
1,
ttWiE
IFF
V
9
E7
rf. A
1. A PLOOD1l OF D PrTn GOES LAC MInMN
A FLOODNAIARO NONE SLIOIIN
l�ID.
vicam'r MAP (N.rs)
AS ON MAP ,IN'0
PER SEAM FIRM PANEL J210 ao K.
: (EN6/NG AWN Pro
ONIS
N ♦1
1_ 140 y
ME
DAMD X. EVE (EL 14) a 0 (Q 17),
L16
RE
GAO
Mw (E105ls�C , ,
MEW
J
2. CORNERS AP
ARE MARKED AS ON LMP.
AS
aw (I
J. ALL BEARINGS ARE 4
ALLBE NO (APRXMEA 2017E
SITE
4. ALL DCOA `U7F ARE 7W COORA FIEID MEASUREMENTS
ORIZOC IL FAE
5. ARMSURI CONNED I?E COOROPMTE
���� PAO9'R1Y IpE AOi SUMIID
— AVN-SLM[tiD LINE
,
Jy �
LE1EXA
H
6 stwt[r wDE wTnatR 6lT4LFR of nTLE EXAM.
O
—w— Rua OR or myDflcm
O BMW ALLAR
0Jy
yP
✓ON MILLER
I I
LOT 38
Mg 5, PG 23
I. ��FL00D
FLOOD ; PHONE FLOOD ;
RECEIVE
XONE 1 (£L 14A ZONE
I (EL 17) 1
MAY - 3 2011
MIRE FENCE _
S 5M24'O8'E
296.58' TOTAL
P
GRASS
24056
WOODEN WALL
BRICK ECM
NEW HANOVER COU
_
WALL /
PLANNING & ZON; P
A4
I
GARAGE
I. y
J
y
20 �3 CONC
�i
�`
MASONRY
HOUSE
GRASS/AC R
�A-GOnio*'
TOPSAIL
S
SOUND
144SCT
\
3D'iET615c'Ic
sLA
SLATES I
/S/FPS \
I
L PAP
nL
M #16
CRASS
HOUSE I
♦ I \,
UK
POINT UNDER
EDGE OF
BRICK PILLAR
L Oan(el H. Thompson, PLS. cer* that this plat sus drown under my aupalv4ion Anon on,
actual field surssy made under my sups , A,o from mfomM rot;m as noted h.; at
the boundaries not surveyed am cNarry
of precision as calculated is 1:10,000+
iMi ofed ca dashed lines; that Me ratio
and is correct to Me best of my bweMdge
and belief. MTtneu my original Sipnoture, License Number and Seal
this day of
. AO, 2017.
Lbniel H. Thompson, PLS If111�(,(n'((.1 I,ZG'
NC Line No. L-2/74 V . 'LgO SQ
XW' a 6{J"44 �vC'h
s (jjT19=Z3S84
•Rarrtuwf0PI4*� 260o SQi�3
SawD twl lyw-' r784
. t W "OvT110%; 1�-lr S�tI
2gS1/"
• natsti 0rvtn lav Sa
50 -W d-XA-r-f'Txx
_VIAL = 51-18 4 SQ
N 50'31'02W 298.70' WALL BRICK WALL
EIP
JAMES MCKEF
"' fT�1 rLLI(�QI
JOIt B,
LOT 36
.�11 u�r kA9�
1 GSM Uk• 1'C'+LRfi'
V
p/1I/IM1G =J %l41F a + ,L�� Sb7 i
AKEENLINES
N FROM
FEW MAP No. I
DATED 2116107
MAP OF SURVEY
FOR
JERRY A. COOK
OF PROPERTY LOCATED AT 8604 BALD EAGLE LANE, WKMINGTON NC
HARNETT TOWNSHIP — NEW HANOVER COUNTY — NORTH CAROLINA
SCALE. 1' — JO' APRIL 2017
30 0 30 60 90
GRAPHIC SCALE — FEET
RE
DCM wi
DANIEL H. THOMPSON, PLS
THOMPSON SURVEnNC CO., PA
209 S. WALKER STREET
BURGAW, NC 28425
[phone]
O N Th9WSa1t flS
W LKiT5E T L-2174
PRI, he c-atls
_IVED
INGTON, NC
7 20117

N e-
9--13
SURYRY AZPZR129M
LOT 37, /44P ROOK 5 AT PAGE 23,
SECTION B, PORTERS NECK PLANTAT70N
PARM: ROJ"-005-014-000
NEW 114NOVER COUNTY R£GISARY
P
---_—_- EIP
�
�2Lu
LU
i
I
U
NOTES.`
- —
1. A PORTION OF THIS PROPERTY DOES LIE WO3NN
Lcom m.
A FLOOD H4ZARD ZONE AS SHOWN ON MAP AND
PER FERN FIRM PANEL 3720 J220 00 K,
ZONES X, YE (EE14) h VE (EL 77),
• EN?S (DUST" MXRQW SPAW
'ANC"
M U
A4TED FEBRU4RY 16, 2007.
ANG (E X6l:VG MW
2CORNERS ARE A14RKED AS NON A14P.
m MW
EPK (X07ED
3. ALL BEill%hL05 ARE WSACTIC NORTH (APR/L 2017).
PROPERTYlS
4. ALL DISTANCES ARE HORIZONTAL FIELD MEASUREA/ENM
PROPERTY LINE NOT SURVEYED
5. AREA OOAMUIED BY TIE COORDAWTE A/ETHOD.
< CI /O4iV IIAK W,NM/T �C•ICCIT K T/Nf fv�,i
— — — — NON-SUPOEYED LW
1, Daniel H. Thompson, PLS, certify that this plot was drown under my supervision from an
xtuol Field survey mode under my au 'akm from information as noted hereon., that
the boundaries not Surveyed are irrdieated as dashed lines., that the ratio
of precision as cokulated is 1:10,000+ and is correct to the test of my knowledge
and belief WTtnesa my odginal Signature,
License Number and Seal
this day of _
, AD, 2017,
Daniel H. Thompson, PLS
NC License No. L-2174
Apra4 .r,'2
- (,Qr1►69=Z3S'84
•p06rv"K0rVlf M 2ban
APT
So w�% 8 4'
• no Cvv v
{SlywC�''Aj �
�
r^'' ..��,�!
• Ir�iTy 01 uo••
Sat-r
L UV•^'
50 LAV
Wiz. 5118 4
Sam —0
prtvm� '� ± Zgo s'Gi r-r TAKEN LiFROM
FEW MAP No.
t+ Ai%Lin K4Ik,- PV+�, we SJ? i: DTEo%D7
MAP OF SURVEY
FOR
JERRY A. COOK
OF PROPERTY LOCATED AT 8604 BALD EAGLE LANE, WILMINGTON NC
HARNETT TOWNSHIP — NEW HANOVER COUNTY — NORTH CAROLINA
SCALE.I" = JO' APRIL 2017
Tr aWTY MAP (N.T.S)
1-1
MAY - 3 2017
PEW HANOVER COL
PLANNING & ZONII
TOPSAIL
SOUND
�£-t 8Irx
un�
R- EC1=1V D
XM WILMINGT N, NC
MAY 03207
D4Nl£L H. THOMPSON, PLS
THOMPSON SURVEYING CO., PA.
209 S. WALKER STREET
BURGAW, NC 26425
[phone]
OWEL N THOMPSON. PLS
NC LACEA6E NP. L-2174
FIRM No. C-a2JD
FXE- NTX-C"

Address_E,ZIP
cityh416(til-1,� 9V*state A/6-s Phone
COL OYL
Email
AUTHORIZEDAGENT
LOCATION OFPROJECT-
to site. Knot oceanfront
adjacentwaterbody.) 11V7_tWt-r,6 r4 f 7ftz__
DESCRIPTION OF PROJECT. (List all proposed construction and land disturbance.)
SIZE OF LOTIPARCEL: 2150#' 'square feet acres
PROPOSED USE: Residential ' (Single-family Multi -family.[]) CommerciallIadustrialff Other
COMPLETE EITHER(1) OR (2)-BELOW (Confaciyour Local Permit Officer if you are not sure which AEC applia
tayourppqpentp):
(1) OCEAN HAZARD AEC9: TOTAL FLOOR AREA OF PROPOSED STRUCTURE:' square feet (includes
air conditioned living space, puking elevated aboveground level, rion-conditioned space elcZt�above ground level but
excluding non -load -bearing attiespace)
(2) COASTAL SHORELINE AECs: SIZE OF BUILDING FOOTPRINTAND OTHER IMPERVIOUS OR BUILT
UPON SURFACES: 2.40 square feet (includes the area of the roof/dripiline of -all buildingg,,drivewaysi covered decks,
i - concrete or masonry patios, etc, that are within the applicable AEC. Attach your calculations with the project drawing.)
STATE STORAIWATERINIANAGENWNTPERART. Is the project located in an area subject to a State Stormwater
Management Permit issued by the NC Division of Water Quality?
YES No ✓
If yes, list the total built upon areatimpervious surface allowed for your lot or parcel: square feet
OTHER PERMITS'MAY BE REQUIRED: The activity you are planning may require permits other than the CAMA
minordevelopmentpennit including, but not limited to: Drinking Water Well, Septic Tank (or other sanitary waste
treatment system.), Building, Electrical, Plumbing, Beating and Air Conditioning, Insulation and Energy Conservation, FIA
Certification, Sand Dune, Sediment Control, Subdivision Approval, Mobile Home Park Approval, Highway Connection, and
others. Check with your Local Permit Officer for more information.
STATEMENT -OFOWNERSHIP:
I, the undersigned, an applicant for a CAMA minor development permit being either the owner of property in an AEC or a
person authorized to act as an agent for purposes of applying for a CAMA minor development permit certify that the person
listed as landowner on this application has a significant interest in the red property described therein. This interest can be
described as: (check one)
' _Z_an owner or record title, Title is vested ig a Mt li- yet f,- see Deed Book ' '42
mtheft,,T-tA/ it3w3diif- County
page Deeds.
W6 - 2 7-40
11 Z, an owner by:virtue of inheritance. Applicantisni heir to the estate of. gEr-E
1, - - - - - KNED
sE probate was in County
—if otherinterem such as written contract or leasie,,explain below or use dseparate 'sheet ,& attach to'Wa6h%aW
NOTIFICATION OF ADJACENT PROPERTY OWNERS: NEW HANOVER COUNTY
I furthermore certify thatthe following persons are owners of properties adjoining this property. I A~9A,RogG
ACTUAL NOTICE to each of them concerning my intent to develop this property and to apply for a CAMA permiL
(Name) (Address)
(2)
(3)
ap (4)
ACKNOWLEDGEMENTS:
I, the undersiguedocknowledge that the land owner is aware that the opmen planned for an area which
propos I tis may be susceptible. to erosion and/or flooding. I acknowledge that the Local P= x has explained to me the particu-
lar hazard problems associated with this lot. This explanation was accompanied by recommendations concerning stabiliza-
tion and floodprooling techniques.
I furthermore certify that I am authorized to grant, and do in fact grant. permission to Division of Coastal Management staff,
the Local Permit Officerand their agents to enteron the aforementioned lands in connection with evaluating information
related to this 't is ti '
on.
This the I, -A- { . day of lhn-Y 20 J
Landowner or pd`r1=1u-thor#ed to act as his/her agent for purpose of filings CAMA permit application
This o"Umdon Includes. general information (this form), a site drawing as described on the back of this application, the
ownership statement, the Ocam HmardAECNotke where necessary, a checkfor $100. 00 made payable to the localiN and
any information as may bepyovidedorally by the ap
plicant, The details oj7ihe application as describedby these sources are
incorporated without reference in anypermil which may be issued. Deviationfivin these derails will constitute a violation of
arty permit. Anyperson developing in anAEC without permit is subject to civil, criminal and administrative action.