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NC Division of Coastal Mgt. Habitat Impact Corr
Applicant: ,e r► 0� (�`n d�/ 1 0��% 7T C5 I.
Date: o311 ij
Describe below the HABITAT disturbances for the application.
All values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
F
(Applied for.
(Anticipated final
(Applied for.
(P
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
di
Habitat Name
Choose One
includes any
Excludes any
total includes
E
anticipated
restoration
any anticipated
re
restoration or
and/or temp
restoration or
to
temp impacts)
impact afml ount
temp impacts)
ai
DA)
Dredge El Fill [I Both El' Other
5
I 5 V
CW
Dredge ❑ Fill ❑ Both ❑ Other
2
�g
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I 1"erety certify tnat i Mr) Property acijacept to
/(Name of Property Owner)
"Gperty iacatec!
(Address, Lot, Block, Road, etc.)
(Waterbody) N C
(City/Town and/or County)
The applicant nas described to me, as sh0wr' below, the development proposed at the above iucatiofi
'Crave no of jeclron to this proposa,
I have ODjCctloris to this proposal
UCZA-KIF I JUN ANLYOR DRAWING OF PROPOSED DEVELOPMENT
(individual Pf - OPOsing development "lust fill in description below of attach a site drawing)
16,g 4'
70'
WAIVER SECTION
"Iderstand [fiat a
0*r dock, mooring pilings, I ' 'reak��a!er. broathouse. lift, Or groin must be set ack xi
"Murn distance n-f 15'fro'n - iv area of riparian access Unless waived by rne. Of voLi w?sh to vv�aj,,,=
Inc, setback yoL, must initial fhe'3PP1`0P"ja'e b;�
1 1. � �j,nti'?'
rtn v"s'- tC vnalve ('ie 15 setloac, requirement
I do not wsii to vwa=ve Sr-lbacj< reqUiremert
[Property Owner Information) (Adjacent Property Owner Information)
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of Typv
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Address

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to J? i h `` Je T T X0 !i A/y s
(Name of Property Owner)
property located at 'D rc
(Address, Lot, Block, Road, etc.)
on in iT. /-J' <" N.C.
(Waterbody) (CitylTown and/or County)
The applicant has described to me, as shown below, the development proposed at the above location.
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)
r^
YJ-1ifl4k 1, j n f i
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.)
(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)
,Signature Signature
Print or Type Name
Mailing Address
Print or Type Name
Marling Address

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