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I hereby certiff
property located at \D j so.\ gv^n S+ (Name or Propertv otnrler)
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has described to me, as shonn below, the development proposed at tfre above
I have ro objection to this proposal.
I have ot{ections to this proposal.
The applicant5L
DESCRIPTION AND'OR DRAWNG OF PROPOSED
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Orner lnformation)Owner lnformation)
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Date
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(ReusedAugr 2014)
P*.\*iuB C,R,erk
(Address,
in
Pe.l e,tM{vtlaterbody)
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WATVER SECNON
I understand that a pier, dock, mooring pilings, boat rarnp, breakwater, bodrcuse, lift, or groin
must be set back a minimum distance of 15 ftom my area of riparian access wrless waiveia by
.me. (lf you wish to waive the setback, you must initial the apprdpriate blank belo,rr.)/I
I do wish to waive the 15 setback requirement.
I do not wish to waive the 15' setback requirement.
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-/'"{ADJAGENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certiff that I onm property adjacentto €uqn n, H BoB\:
foperty located at loz So[eu".'+(Name of Property Orner)
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P in . N.C.$ee- (Waterbody)g
The applicant has described to me, as shorm below, the developnent proposed at the above
location.
I hare rrc obiection to this proposal.
I have objeciions to this proposal.
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DESCRIPTION AND'OR DRAWNG OF PROPOSED DB/ELOPMENT(lnffiual poposing
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WAIVER SECTION
I understand that a pier, fuk,mooring pilings,boat ramp, breahrater, bodpuse, lift, or groin
must be set back a minimum distarrce of 15'fr,om my area of riparian access mless waived by
me. (lf you wish to waive the setback,yor must initial the appropriate blank belotu.)
I do wish to waive the 15 setbrck requirement.
I do not wish to waive the 15' setback requirement.
Ormer lnformation)(Adjacent pnoperty Onrner lnformation)
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Tebphorc Nwber / efilaiil address
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Date
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Datii - I
(Revzsed Aug.2014)
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