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62446A - Blackmore, Small, Grube, Thomas and Adams
CXtAMA / XDREDGE & FILL N 6?,44F GENERAL PERMIT Previous permit# VNew []Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued As authorized by the State of North Carolina, Department of Environment and Natural Resources and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC ^ (, �' I ( o EZ Rules attached. Applicant Name III 1jinmunkeulefij, ekre ,r4.1ljFdJlin -. ( (iVG;(d Thomns Frnk ams Address n. r ,.' „n City,+t C State NC ZIP Q Phone # ( ) Fax # O Authorized Agent (I��S�fw Vlai, Ifl f Affected LlCW aJEW OPTA R�tEs ❑PTS A AEC(s): OE ❑ HHF ❑ IH LJ UBA ❑ N/A ❑ PWS: ❑FC: ORW: yes / no PNA yes /(66) Crit.Hab. yes /�no ) Project Location: County Street Address/ State Road/ Lot #(s) Lot 5 1 I S I Subdivision ' �j7lyt ( (JQ CityJ I—q If 0 ZIP 7IJ 5 Phone # () ff River Basin Adj. Wtr. Body (I(LI\Cyl �natl/man/unkn) Closest Mal. Wtr.Body 'i—)DanbGg�Dllhr - ■ ■ ■■■■ ■■ ®■■■ ■■■ CN�®®C�■::::�C■. EMMEMEM N ME ME ME I ME .. ■■■ ■0■■■ ■■■ MEN ■■MIN ■� MOM■■: ::OMEN ME MEMO MEN ■■ ■■■■ ■■ ■■■ ■�■ ■■■■■ ■■■■ =11C�■■■iCi ■.i■■■®i■OM■iC■�■..■■■�C■... ®■■■ ■■■■ ■■■■■ ■■■ ■■■■■ IN groom ME NOMESE■■�■■■:�nE:�l�J■■■K■■l�■�: ME 0 �IN M M MIN., Mol-0 IM■■ ■■ io ■m■ ■■��■■■I ®C: NEE 0 -'ruf ME ME ■ IiG f11190=2r�rl®■ ■■■■ ■■■■.� ■■■w■■■ NONE MEE .i� EE 0tME ME mom Agent or Applicant Printed Name Signature " Please read compliance statement onback ofpermit" Application Fee(s) Check # N.C. DIVISION OF COASTAL MANAGEMENT AGENT AUTHORIZATION FORM Date / /'- /g r� Name of Property Owner Applying for Permit: Mailing Address: �!-D 6b-k (Wf 41tL,7',C0 �0.4 , I certify that I have authorized (agent) lkli,,2 to act on my behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to install or construct (activity) A ,tl zO a6ilMizol) at (my property located at) L D7S Y 16 % z-- l P %Y This certification is valid thru (date) %cP — 34 '- Property Owner Signature 1a? - j Date 12109/2013 10:06 C.A. Perry Weeksville (FAX)2523303588 P.0021004 35 is DIVISION OF COASTAL MANAGEMENT ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION FORM CERTIFIED MAIL - RETURN RECEIPT REQUESTED I hereby certify that I own property adjacent to 4)sL1-1;,.14- 12L42Q a /LIp22 s (Name of Property Owner) property located at (Address, Lot, Block, Road, etc.) on )-tA,-zAiv&j7 Srk z,n In, r�-" 'rr N.C. (Waterbody) (City/Town and/or County) Agent's Name #: % ka Cz9al fln,n!>_h:.•>"� Mailing Address: T Agent's phone #: _ i — 41 Wg_ ¢&gn.?r,lh,21 _ He/She has described to me as shown below the development he/she is proposing at that location, and I have no objections to the proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (Individual proposing development must rill in description below or attach a site drawing) �vuSTiii,t- A kltcv 6-0 tr you nave objections to whatls being proposed, you mustnotrfy the Division of Coastal Management (DCM) In writing within 90 days of receipt of this notice. Contact Information for DCM offices is available at www.nccoastaimangement.net/contact dcm.htm or by calling 9-888-4RCOASL No response Is considered the some as no objection If you have been notified by Certified Mail (Property Owner information) Signature t,-)Lll-, r, 141� Al b n PRnt or Type Name Mailing Address >�n/t„} •rail_-_ N�. C, �7S•37 City/state2ip Telephone Number Date (Riparian Property Owner Information) Signal 3r1=/�i�� 5n PnntorType Wme _4--2G St,o L. i, /)2xde Mailing Address Amyl 7/ 1 city/stare/zip Telephone Number ►2.-Fs-�3 Date 11/20/2013 09:48 2524734200 PIRATES -COVE #1253 P.002 11/20/2013 03:49 2524734200 PIRATES -COVE #1253 P.003 11/20/2013 03:51 2524734200 PIRATES -COVE #1253 P.004 1210912013 10:07 C.A. Perry Weeksville (FAH)2523303588 P.0041004 DIVISION OF COASTAL MANAGEMENT ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION FORM CERTIFIED MAIL - RETURN RECEIPT REQUESTED I hereby certify that I own property adjacent to R 6�)1nL(_ s ( ame of Property Owner) property located at Ito ,Vt AOMAkAI\ _ (! <�27-- (Address, Lot, Block, Road, etc.) on Alll2 II Ln � Ay')i ,in 6nO�JTTO N.C. (Waterbody) (City/Town and/or County) Agent's Name #: a � ,1 c,, A1sVLr&6 j,- Mailing Address: P) �, , ni)`k- C Agents phone #: �_��— / j� - 2.64! •97 > _ He/She has described to me as shown below the development he/she is proposing at that location, and I have no objections to the proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (Individual proposing development must till in description below or attach a site drawing) 8JL/'� /-� LZ)7�5 O'J it you have objections to whatisbeingproposed, you must notrfythe Division of Coastal Management (DCM) In wr/Bng within 10 days of receipt of this notice. Contact information for DCM offices is available at www.nccoastaimangement.nettconteciLdcin.htm or by calling 1-888.4RCOAST. No response is considered the some as no objection if you have been notified by Certtued Mall (Property Owner Information) 4A Z <�r+e,C.J. Signalu Print or Type lltaim `/�(gpA t� g Address ch 7 J ciryisrareizip 2S7- 333 276k Telephone Number 12-g—r 3 (Riparian Property Owner Information) Signature G Lca��u ,DLO& 2ant?n Print or Type Name 161 m.j-a : o p_--dre Mailing Address _ A< -)To,,) 2 Crty/State/Zip Telephone Number Date Date DIVISION OF COASTAL MANAGEMENT ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION FORM CERTIFIED MAIL - RETURN RECEIPT REQUESTED I hereby certify that I own property adjacent to F_ r 2rLu i( Is n (N me of Property Owner) property located at 062-r" (Address, Lot, Block, Road, etc.) on lk&j 40i)L2, in N.C. (Waterbody) (City/Town and/or County) Agent's Name #: M> u . <7 �J 2 /y1,22�Jr2 Mailing Address: Agent's phone#: lVra/'iirJ1,i,,L IV.C, -'279yI He/She has described to me as shown below the development he/she is proposing at that location, and I have no objections to the proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (Individual proposing development must fill in description below or attach a site drawing) �-DT5 l,T / � / 17l l h'/ / If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM1 in writing within 10 days of receipt of this notice. Contact information for DCM offices is available at www.nccoastalmangement.neticontact dcm.htm or by calling 1-888-4RCOAST. No response is considered the same as no objection if you have been notified by Certified Mail. (Property Owner Information) Signature �; —0oa L Print or Type Na e Mailing Address jzt t2n/�, l�J Car-, City/StatelZip Telephone Number (Riparian ProperWPvMef Information) Signature/ r l/ ' (f i 7 - IC6Itn 9yy MA i Print or Type Name i U, UY�': ,,gy�p �\x C r>7 i J Mailing Address G �) tJn 7 �, �, �,27So,5' CitylStatelZip Telephone Number Date Date I hereby certify that I.own propE;rly adjacont to 10,1,tom (Name of Property Owner) Itroperry located at.,<:� �'_...��,'�:1D<11 t +� �} f 3 > ! (Address, Lot, Block Road, etc,) (Waferbody) (Cityrfnwn and/or County) `v Agent's Name #. Mailing Add€ess, Agent's phone hlL�l,3he hps described to me as shown below the devolopirent hotslre is proposing at that location, and I baye ne, abjrZion,, to the proposal, DESCRIPTION ANDlOR DRAWING OF PROPOSED DEVELOPMENT (Individual prop4sin,q develoinnont must fall in description below or atfach a s+(e drawing) c 1) --j j. 1 J / 1. Gi'j",� /} tl IfycrutraverndjeeldonsgawRetlabetngproptisrd,yaurnrstnotlffytheUrvJstan if Coastal/anagentrttt {OGhP} ineirfttng wfthfrt'90 days 01 retpt of tht5 natica�, CantacE infannatiart far i7!`;"t aNfcns s avadlnEplo t wanvncep staftn rryantent neUccntac2 dcnr.htrtr or `try ct;itlnr�- 9-888- R ©r1Sg. F o aswnse Is considereii f110 s�rnrs na objer,tkin it you h rve hee>rl iraf tied by Lett fietf M aJl (Propterty, (Riparian Prol)arky Owiker Information) Sr�t>ttu Tier orType 'Natne Print or Type. Name M/uff)ijng�Addims 7 f Mailing Address atof City StafrJZi Cityistatelzip 7 1 5 g 71? Tate}rhorte Number, `•�--•-- !elophone.Pti;nfber DIVISION OF COASTAL MANAGEMENT ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION FORM CERTIFIED MAIL - RETURN RECEIPT REQUESTED hereby certify that I own property adjacent to tO Pc�-T ur 6Q6fi 's (Name of Property Owner) property located at 1 h ,SPT-NfJ Akil d , U'6 ay� , (Address, Lot, Block, Road, etc.) on .n �>1N.1--) ,in N.C. (Waterbody) (City/Town and/or County) Agent's Name #: 4 ,�.43: �2 _ ,n; s,J n Mailing Address: L) , /u S 7 Agent's phone #: �S, 2— c,,� Z .2!2, ' A) is ; 27y 7 He/She has described to me as shown below the development he/she is proposing at that location, and I have no objections to the proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (Individual proposing development must fill in description below or attach a site drawing) �03',/-RtL A 11v-�0 i( 61,k1� 9A0 � L DYS f S/ / l / n/ /�5/ % 7 rr you nave on/ecuons to what is demg proposed, you must notify the Division of Coastal Management (DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is available at www.nccoastalmangement.net/contact dcm.htm or by calling 1-888-4RCOAST. No response is considered the same as no objection if you have been notified by Certified Mail. (Property Owner Information) Signature W L t,- b Z- (i Print or Type Name Mailing Address /,1,.>Pr:2.� A -)a 1� / rA(- City/StatelLip Telephone Number Date (Riparian Property Owner Information) Signature r(Zn.3� M#t4l t Print or Type Name A 6, J6 X R/ Mailing Address ,W fWr-p J , L 2 S" CitylStatelZip Telephone Number Date DIVISION or COASTAL MANAGEMENT ADJACENT RIPARIAN EROPERRTY OWNER NOTIFICATION FORM CCRTIFICG> t: - RL-'TURN RECEIPT RrQU�ST �p 1 hereby certify that I own property adjacent to s at pro(Naine of Property Owner) , erty located tF�z _ �, ? lvarY 1l � ' ('v i _�_ _ _..� .__ ice. _ �� (Address, Lot, Block, Road, etc.) (gVater#aody) (CHyfrown and/or County) Ayeat's Idartiefil. J# 1 iLc L'j°' 7 L, » Mailing Address` Agent's phone#: Ho/She has described to me as shown below tite development he/she is proposing at that location, and l have no objections to the proposal. DESCRIPTION ANDPOR DRAWING OF MOPOSCI) D VE OPMEN'I- (trsdividtial proposing dolfeloiarnutlt rrrust rill in description below or attach a site drawl iq) i i i f } ou ftuva ofijecUorrs to w'irat736einproposed yountustnoirFyii a i)fvisian oFCoaatalt✓]anayerrrclit (!)CM) in wrhlilq within 10 days of receipt of this notice, ConhTct taionrration for Dok, , vofics aystia?le if wwncc,as7me ftnafoi.nis or by &ailing. 1-888-4RCOAST rts is N Lt- pooon_wirtat ii tiro sama as ou a ctron ifyotr ltavP hQen na€rFi qrY fled Marl y tx (Pe opoily Owner In ormatiora r a a {k2rparian Properly e 3e Infarntateorr} j S, rratrxro�� ,teaf� �x i q Srgn it , l Fine or Typo Namo Prim or' typo Nomo i, ai&ng Address Mailing Add!oz LI'-" ... ^.F it Cf}1S/�alc7ip } j rity/Staftl7rp, t 7i>l<.piranoNunabWr _-� ..._ 7"s(ephrjwr Noinbet f a p Lam.: Data Datr, DIVISION OF COASTAL MANAGEMENT ERTIFIED MAIL - RETURN RECEIPT REQUESTED I hereby certify that I own property adjacent to (Dg o )r' 's (Name of Property Owner) property located at_._., C P'�vJ. A k a t 6L) f�•T--- (Address, Lot, Block, Road, etc.) on in p N.C. (Waterbody) (CityrTown and/or County) Agent's Name #: 2A" zimia _ AW1 z4n Mailing Address: f L 17 Agent's phone #: 2, S-7 - � I- � A111OT 6 (c A X) C 7`} He/She has described tome as shown below the development he/she is proposing at that location, and I have no objections to the proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (Individual proposing development must fill in description below or attach a site drawing) J-YJ S-,ry t, (, A /0 It c i d5J o i If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is available at www.nccoastaimangementnet/contact dcm.htm or by calling 1-888-4RCOAST. No response is considered the same as no objection if you have been notified by Certified Mail (Property Owner Information) Signature Print or Type Name _I Mi 1J1A /.frlr 1L) MadmgAddress p (xy/S ate/Zip Telephone Number Date (Riparian Property Owner Information) Signal r -(fL ZG_F-hlZ/\ Print or Type Name Mailing Address Nbf)d)(4!n4 City/State2ip Telephone Number Date DIVISION OF COASTAL MANAGEMENT AIJJAC EN'' RIPA%kq PEOPLRI' y ()VA!NCR, RgTl lCATION FORM CEwirir-D MA I4 - NLTORN RMPAPT t#[aOUES"TEt) I hereby certify, that I own property, adjacent to p (Phone of Property Owner) property Ideated at (tAddress, Lot, Block, Road, etc.) on J9 � Cr 1� t s): ' a. in, N.C" (Waterbody)(City/Town andlor Ciaunty) Agent's Name # /Y1x,t3a Mailing Address. S__ W Agent'sphone _ ilry IieJSttea has described to me as shown below the development heJshe k proposing at that location, and i have no objections to the proposal, DESCRIPTION ANlJlOk DRAWING OF PROPOSLE) DEV11LOPM NT__: (InelWdua proposing doWtopinent must fill in descYipflotr below orattach r site drawing) If you 11iveohje0Yon s tb vrhsf is b0Ing propnseri, you mast notify the 77ivisPon ofCaastal h9anayanrent (DCM) in vrr btt•rl veltirin 10 days of ratceipt of this notteL. Contact Information for DCM r th"s Is avull:71310 at tvrfvr.nccaiisfulrnarig nrent.rreUcontacY_dcm.htnr or by callinti t-8884RCOAST. No re jrott.,e rs odhst•ctcrmd:iho nts„�ds no A1FicFiotr if y4 have b en irot+Jr ti fry LerYrfred -mail _ (Properly flwnor Infolyn adon) (Riparian Property C> ner Information) Pact rr iypoWirno ;in -type F,rrliPurNemr. Maifiny Add ess Mailing Address Cilyl�I�rtelZ7p �_ cilyStatellip %i:3photto`NurnherTM' 7slophotto Ntirnhor �'" ✓aahi DIVISION OF COASTAL MANAGEMENT ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION FORM CERTIFIED MAIL - RETURN RECEIPT REQUESTED I hereby certify that I own property adjacent to Fri iwk ,fir1AM l 's (Name of Property Owner) property located at 1a CE)J ('s r— , (Address, Lot, Block, Road, etc.) on 4l (3e„n(ll.;.z _ JaJ)/I in Mlotl TlLJ N.C. (Waterbody) (City/Town and/or County) Agent's Name #: Mailing Address: Jn, t) . �i k ,Cr�7 Agent's phone #: ,$ 2 y44 — He/She has described to me as shown below the development he/she is proposing at that location, and I have no objections to the proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (Individual proposing development must fill in description below or attach a site drawing) 14L)�yAL(, A )0(,-- J 141lr),,10 t)rJ /7i If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is available at www.nccoastalmangement.net/contact dcm.htm or by calling 1-888-4RCOAST. No response is considered the same as no objection if you have been notified by Certified Mail (Property Owner Information) SijnatuW Pnnt or Type Name P, �).: l/)u ?/R Mailing Address A),C, -,:? City/State2ip Telephone Number (Riparian Property Owner Information) Signature fJtLC %�a , 6 JAI/ Print or Type Name )'3?a. 41) /jrt Mailing Address cbbp l' rS Jz (, P� City/State2ip Telephone Number Date Date DIVISION OF COASTAL MANAGEMENT ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION FORM CERTIFIED MAIL - RETURN RECEIPT REQUESTED hereby certify that I own property adjacent to % zowk &)o-vm < 's (Name of Property Owner) property located at C t) 6 0-*T— (Address, Lot, Block, Road, etc.) on , in n) n.,) r/to N.C. (Waterbody) (City/Town and/or County) Agent's Name #: ir'ruf 7-A-x-)ro Agoar,.ln Mailing Address: Agent's phone#: V a -94A61-- a-- t). 27!� LZ/ He/She has described tome as shown below the development he/she is proposing at that location, and I have no objections to the proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (individual proposing development must fill in description below or attach a site drawing) �T- rU,�>Tn(-(/I- I0iLL?) b0J-k/)g-v �>0 If you have objections to what is beingproposed, you mustnotify the Division of Coastal Management (DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is available at www.nccoastalmangement.net/contact dcm.htm or by calling 1-888-4RCOAST. No response is considered the same as no objection if you have been notified by Certified Mail. (Property Owner Information) J//r Signature Eaa wk Au�)a&,u Print or Type Name Ar). 11N4 .? 8 Mailing Address M✓zi"rz 0 A) C, �z7I S-Y City/StatelZip Telephone Number (Riparian Property Owner Information) d" Sign ture r-9n wk ✓Olww,S Print or Type Name P, D, 06-k el y Mailing Address A✓3V /lvD Ai, C., 1 City/State/Zip Telephone Number Date DIVISION OF COASTAL MANAGEMENT RJAg =t �IAN PROPERTY Qt NCR NOTIFIGA_,TLON FORM CERTIFIED MAIL - RETURN RECtIPT REQUESTED liercby certify that 1 own property adjacent to 2 )� j if i; (Nance of Property Owner) property located at (Address, Lot, Block, Road, etc:) oil A in _.. _. (Waterbody)' (City/Town antilorCounty) q L Agent's phone#:5.{L I lef5he has described to 'neasshown below file development he/she is proposine g at that (acation, and I have no ab)etations to the proposal, _.___., ___ __ _________ DESCRIPTION AND1611 DRAINING OF PROPOSED DEVELOPMENT ' (Iradividua(propcfsing-developinlerit most fill in description below✓ or attach a site rlratving) tty0t1haveobjectionsfowhatfsbomgprcin050d YOU nitistnotify theDiVisionofCoastal ftnagetnent (I)CAI) to Writing avithig 10 flays -of receipt of this notice. Contact tnfoOnaation for DCM offices is - arattable,at dcrn.htrri or by Calling 1-888-4RCOASr, No rasprnry t5 eonsrctr rr ri the sarrti as no obiechon if yoai.,ftgvo boerp'not7fFed Corlftiof t lrtatl (Trope ntr Owner Information) (Riparian Properly.pt ejr/Information) S,gnatrrre Sin Fn»f or 7 yrrr, N<nao Print or I ypa N,,voo r � r u i`S - - _ f.,5ll hZifnog .Address - .. Marlrrzg Address (±�... C-�{�'t �t `i�U14... %�n.�!�L.t � �c.�,{✓. t7" ) �_ _7 Cr(y/5tatefliti CityfStatetZrls � Totophono Numbor TolophonNumb Dafn Dhto 12/09/2013 10:07 C.A. Perry Weeksville (FAX)2523303588 P.0031004 DIVISION OF COASTAL MANAGEMENT I hereby certify that I own property adjacent to %d& .n, ya ( 's (Name of Property Owner) property located at..... %7 5�7iJ,J/Ll�fz/J CD)q-r— (Address, Lot, Block, Road, etc.) on l� `/S2 ninf , r r Sn1 f , / , in _ �J1la il T i N.C. (Waterbody) (Cityrrown and/or County) Agent's Name ,1,,qA,;,, , Mailing Address: /[) e), Pf )Z. Agent's phone#: as-�- 1 26zi 61-&- /J C a 7^ ! He/She has described to me as shown below the development he/she is proposing at that location, and I have no objections to the proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (individual proposing development must fill In description below or attach a site drawing) Lo 7-s )� / �1 / 7 (ACM) In writing within 10 days of receipt of this notice. Contact information for DCbfoffices is available at www.nccoastalmangement.neflconfaciLdcm.htm or by calling 1-888.4RCOAST. No response.ts considered the same as no oblection if you have been notified by Certilled Mail Usi ing Address 621t el' c— Cdy/state/Zip Telephone Number Date (Riparian Property Owner Information) Signet& ( ' �� FFAF N Smo LI Print or Type Noe a (a Gh, / I- Mailing Address r�yzry�l�Ti,� czr�1 iJC 2�cir� City/State2/p J �52- 33 3 236� Telephone Number Date DIVISION OF COASTAL MANAGEMENT CERTIFIED MAIL - RETURN RECEIPT hereby certify that I own property adjacent to GZ'rl%oC) l /kL>'hn 's (Name of Property Owner) property located at (Address, Lot, Block, Road, etc.) on /1�/Yz„ua,2t;e ,in /�I/I0Ti,U N.C. (Waterbody) (CitylTown and/or County) Agent's Name #: illr-z� yri oa% /tr,nn -?Wrt _ Mailing Address: irey , in X S` 7 Agent's phone #: a C ;�- —_ fr `3 ) — � s iT �4,wlS%ivGr42, I0 , 6, 2 TT NI He/She has described to me as shown below the development he/she is proposing at that location, and I have no objections to the proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (Individual proposing development must fill in description below or attach a site drawing) I-DTS r�.- ivf��"D 0/0 ISM l�� 17�/V If you have objections to what is being proposed, you mustnotify the Division of Coastal management (DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is available at www.nccoastaimangement.net/contact dcm.htm or by calling 1-888-4RCOAST. No response is considered the same as no objection if you have been notified by Certified Mail. (Property Owner Information) Signature Pdnit or Type Name Mailing Address City/State/Zip Telephone Number Date (Riparian Property Owner Information) Signature '7r-- FFF A F-V Srn,o r r Print or Type N e 1 9 � S171 / 1 t, L A,r2 r0fz Mailing Address rL12/16K7/� GLTti l�%C. 2�ej� City/State/Zip Telephone Number Date