20130397 Ver 1_401 Application_20130413

O�0� W ATE9OG
20130397
Office Use Only
Corps action ID no
DWQ project no
Form Version 14 January 2009
Pre - Construction Notification (PCN) Form
A. Applicant Information
r
1. Processing
1a. Type(s) of approval sought from the Corps:
❑X Section 404 Permit ❑ Section i0 Permit
1b. Specify Nationwide Permit (NWP) number: 18 or General Permit (GP) number-
1c Has the NWP or GP number been verified by the Corps?
❑X Yes ❑ No
1d. Type(s) of approval sought from the DWQ (check all that apply):
Q 401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
1 e Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification•
❑ Yes ❑X No
For the record only for Corps Permit.
❑ Yes ❑X No'
1f Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in -lieu fee program.
❑ Yes ❑X No
1 g Is the project located in any of NC's twenty coastal counties If yes, answer 1 h
below
❑X Yes ❑ No
1h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes Q No
2. Project Information
2a Name of project:
2b. County
Beaufort county
2c Nearest municipality / town:
Washington, NC
2d. Subdivision name: Riverwalk II
2e. NCDOT only, T I.P. or state project no.
3. Owner Information
wig
3a Name(s) on Recorded Deed William Joseph Crocker Jr
ARD
3b Deed Book and Page No.
013
3c Responsible Party (for LLC if
applicable)
D1rA K UAII
3d. Street address
38 Rrverwalk Drive anch
3e City, state, zip
Washington, NC 27889
3f. Telephone no
252- 972 -1768 or 252 - 314 -2528
3g Fax no
3h Email address
wicrockerir @suddenlink net
Page 1 of 10
PCN Form — Version 1 4 January 2009

4. Applicant Information (if different from owner)
4a. Applicant is:
❑ Agent ❑ Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:.,
4f. Telephon o ?: �.
4g. Fax no '� 8
4h. Email address:
S. AgentlConsultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 10

B.
Project Information and Prior Project History
1.
Property Identification
1a
Property identification no. (tax PIN or parcel ID):
6603 -47 -5186
lb
Site coordinates (in decimal degrees):
Latitude-35',4 q /. a s IV Longitude: &7 S
1c
Property size
.32, acres
2.
Surface Waters
2a. Name of nearest body of water to proposed project*
Pamlico River
2b
Water Quality Classification of nearest receiving water:
NSW SB '
2c.
River basin•
Tar - Pamlico
3.
Project Description
3a Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application
Subdivision- Wetland backs up to foundation of house
3b
List the total estimated acreage of all existing wetlands on the property: 0.34 Cacr t s
3c
List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
3d. Explain the purpose of the proposed project:
Fill in wetland area close to house foundation
3e Describe the overall project in detail, including the type of equipment to be used-
Fill material, topsoil and sand. Installing silt fence Planting grass seed. Equipment used will be dump truck for hauling fill in material
4.
Jurisdictional Determinations
4a
Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
X❑ Yes ❑ No ❑ Unknown
Comments
4b
If the Corps made the jurisdictional determination, what type
of determination was made?
Preliminary ❑ Final
4c
If yes, who delineated the jurisdictional areas?
Name (if known)• William Wescott
Agency /Consultant Company:
Other-
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5.
Project History
5a
Have permits or certifications been requested or obtained for
this project (including all prior phase`s) in the past?
Yes Q No El Unknown
5b
If yes, explain in detail according to "help file" instructions
6.
Future Project Plans
6a
Is this a phased project?
❑ Yes ❑X No
6b
If yes, explain
Page 3 of 10
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1a. Which sections were completed below for your project (check all that apply):
Q Wetlands ❑ Streams — tributaries ❑ Buffers ❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted
2a.
Wetland impact
number
Permanent (P) or
Temporary
2b.
Type of impact
2c.
Type of wetland
2d.
Forested
2e.
Type of jurisdiction
Corps (404,10) or
DWO (401, other)
2f
Area of
i impact
(acres)
W1 P
Fill
q /You
No
Corps
004
W2
Choose one
Choose one
Yes /No
W3
Choose one
Choose one
Yes /No
W4
Choose one
Choose one
Yes /No
I
W5
Choose one
Choose one
Yes /No
i
W6
Choose one
Choose one
Yes /No
2g. Total Wetland Impacts:
004
2h Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a.
Stream impact
number
Permanent (P) or
Temporary (T)
3b.
Type of impact
3c.
Stream name
3d.
Perennial (PER) or
intermittent (INT)?
3e
Type of
jurisdiction
3f
Average
stream
width
(feet)
3g
Impact
length
(linear
feet)
S1
Choose one
S2
Choose one
S3
Choose one
S4
Choose one
S5
Choose one
S6
Choose one
3h Total stream and tributary impacts
3i Comments:
Page 4 of 10
PCN Form — Version 1 4 January 2009

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U S then indivii ually list all open water impacts below
4a
4b
4c
4d
4e.
Open water
Name of waterbody
impact number
(if applicable)
Type of impact
Waterbody
Area of impact (acres)
Permanent (P) or
type
Temporary T
01
Choose one
Choose
02
Choose one
Choose
03
Choose one
Choose
04
Choose one
Choose
4f. Total open water impacts
4g Comments
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below
5a
5b.
5c
5d
5e
Pond ID number
Proposed use or
Wetland Impacts (acres)
Stream Impacts (feet)
Upland
purpose of pond
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f. Total:
5g Comments
5h Is a dam high hazard permit required*
Yes No If yes, permit ID no
51 Expected pond surface area (acres)
5i Size of pond watershed (acres)
5k Method of construction,
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below If yes, then individually list all buffer impacts
below If any impacts require mitigation, then you MUST fill out Section D of this form
6a. Project is in which protected basin?
❑ Neuse Tar - Pamlico Catawba [] Randleman [3 Other
6b
6c
6d
6e.
6f
6g
Buffer Impact
Reason for impact
Stream name
Buffer
Zone 1
Zone 2
number —
mitigation
impact
impact
Permanent (P) or
required?
(square
(square
Tem ora T
feet
feet
61
Yes /No
Yes /No
B2
63
Yes /No
B4
Yes /No
B5
Yes /No
66
Yes /No
6h Total Buffer
Impacts:
� 61 Comments
I
Page 5 of 10

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
Minimum fill needed to protect foundation
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
silt fence
retain wall
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State
❑ Yes X❑ No
2b. If yes, mitigation is required by (check all that apply),
❑ DWQ ❑ Corps
2c If yes, which mitigation option will be used for this
project?
❑ Mitigation bank
❑ Payment to in -lieu fee plogram
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a Name of Mitigation Bank,
3b. Credits Purchased (attach receipt and letter)
Type Choose one
Type Choose one
Type Choose one
Quantity
Quantity*
Quantity
3c Comments
4. Complete if Making a Payment to In -lieu Fee Program
4a Approval letter from in -lieu fee program is attached
❑ Yes
4b Stream mitigation requested
linear feet
4c If using stream mitigation, stream temperature.
Choose one
4d. Buffer mitigation requested (DWQ only)-
square feet
4e. Riparian wetland mitigation requested.
acres
4f. Non - riparian wetland mitigation requested.
acres
4g Coastal (tidal) wetland mitigation requested
acres
4h Comments*
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan
Page 6 of 10
PCN Form — Version 1 4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation?
❑ Yes G 140
6b If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
Zone
6c.
Reason for impact
6d.
Total impact
(square feet)
Multiplier
r
6e.
Required mitigation
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
1.5
6f. Total buffer mitigation required:
6g If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund).
6h. Comments
Page 7 of 10

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
la. Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules?
Yes ❑x No
1b. If yes, then is a diffuse flow plan included? If no, explain why.
❑ Yes ❑ No
2. Stormwater Mana ement Plan
2a. What is the overall percent imperviousness of this project?
0 %
2b. Does this project require a Stormwater Management Plan?
❑ Yes No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e. Who will be responsible for the review of the Stormwater Management Plan?
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
3b. Which of the following locally - implemented stormwater management programs
apply (check all that apply):
❑ Phase II
❑ NSW
❑ USMP
❑ Water Supply Watershed
❑ Other:
3c. Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ Yes ❑ No
4. DWQ Stormwater Program Review
4a. Which of the following state - implemented stormwater management programs apply
(check all that apply):
®Coastal counties
❑HQW
❑ORW
❑Session Law 2006 -246
[-]Other:
4b. Has the approved Stormwater Management Plan with proof of approval been.
attached?
❑ Yes ❑ No
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements?
® Yes ❑ No
5b. Have all of the 401 Unit submittal requirements been met?
® Yes ❑ No
Page 8 of 10
PCN Form — Version 1.4 January 2009

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal /state /local) funds or the
❑Yes
�TVo
use of public (federal /state) land?
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State
❑ Yes
❑ No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.)
❑ Yes
❑ No
Comments.
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H 1300), DWQ Surface Water or Wetland Standards,
❑ Yes
No
or Riparian Buffer Rules (15A NCAC 2B.0200)?
2b. Is this an after - the -fact permit application?
❑ Yes
Q No
2c If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a Will this project (based on past and reasonably anticipated future impacts) result in
C1 Yes
ONo
additional development, which could impact nearby downstream water quality?
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non- discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
on g,+c saPiic. sys+e ")
Page 9 of 10
PCN Form — Version 1.4 January 2009

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
❑ Yes Q No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
❑ Yes ❑X No
impacts?
5c. If yes, indicate the USFWS Field Office you have contacted.
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
Subdivision documents did not identify any list species or their habitat.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
❑ Yes x❑ No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
No impacts to open water.
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
❑ Yes x❑ No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
Subdivision documents did not identify that it would impact historic or archeological resources.
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA- designated 100 -year floodplain?
❑X Yes ❑ No
8b. If yes, explain how project meets FEMA requirements:
Filling of 0 04 acres of wetlands will not result in Increased flooding on adjacent areas.
8c. What source(s) did you use to make the floodplain determination?
FEMA Flood plan map
Applicant/Agent's Printed Name
A licant/Agent's Signature
Date
(Agent's signature is valid only if an authorization
letter from the applicant is provided.)
Page 10 of 10

:[STING IRON PIPE N 06 35 33 W- 12.34' C1 C2 C3
I ST I NG IRON ROD N 80 49 41 E -1 1 , 58' R= 235.15' R= 235.15' R= 250.81'
W IRON STAKE A = 7 °39'50" A = 24 °05'16" A = 02 °56'04"
1 POINT SET L= 31.45' L= 98.86' L= 12.85'
CORNER BULKHEAD CH= N26 °21'29 "W CH= N42 °13'40 "W CH= N52 °48'17 "W
GHT -OF -WAY 31.43' 98,13' 12.84'
IER POLE
XISTING RAILROAD \ C4 C5 C6
E 0 ?207 °44'40" ZS 300.81' 2 °28'36" A 322 °02'30"
ENNEAD UTILITY L= 121.45' L= 65.50' L= 115.72'
= TELEPHONE PEDESTAL
KNEAD CH= N37 °30'25 "W CH= S25 °29'50 "E CH= S42 °45'23 "E TROL CORNER -- - _______ � 119.98' 65.37' 115,01'
RiW S�
PERTY LINE T
T TO SCALE // -' -� j C7 C8 C9
XISTING PARKER KALON NAIL tP$ f3j3) �, 06 R= 300.81' R= 185.15' R =- 185,15'
_ A = 0 29'47 0 = 26 °41 41 0 - 5 03'25'
-El5 E P is1i2.54'20 "E / /Pp S L= 2.61' L= 86.26' L= 16.34'
15,89' 77'(707) IS ^ 60, RyF� CH= 554 °01'30 "E CH= S40 °55'26 "E CH= S25 °03'45
BLDG BY OTHERS 10.26' t t. 0 •� �oAR� 1�! 2.60' 85.49' 16.34'
ENCROACHES A MAX OF 5.6' S•3Q'' %
EDGE OF GRAVEL 21 53' " ",R'w \4,e4i S
(WETLAND LINE) 4� N24.2? 40'E „� SS \ F FS 4j
I ' 2 C -1 e5.37 & �.�• _ e•, R,. 94 ?' NOTE: THIS MAP SUPERSEDES MAP OF
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PILINGS 8t• OTHERS /C� �� 3Y ' D -1 PRIVATE �0 �� „_�• 123 42.95' 2
ENCROACH A MAX OF 2.9' P a� / ® 1 + k 554.1 ' 25 "E °�' � - ;;�• 'k- �• 93 Is $B4.
m / C 301 53-79 ¢ �y ,r" 46' 53 "E
16 C7 yy'� 0 D1 17 a. O 1 ti0 may"` ,rte .w- 171.48' Is
t ,r alir r ,r '�` r n. EIS
SWAN POINT �' / M ryo a %� t e do 'k ` �• y. y` 404
y1 ^ \ i1 S5 10' WATERL IN ■. 'ra. "' WETLANDS 4 ,'�`�+� '�`• 3
25 �9 EASEMENTa.a ,r +� �" IPA
(4.0477 AC)
N A3 i 6 A3,_ 2e �. 21 \. `' 2 : 404 WETLANDS LINE �' '" �.-
/
o 1)S °3 a3Y o �4a A 7 23 C
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\ SEE NOTE 4.
/
WHICH ARE SPECIFIED AS BUILDING LOTS
A6,���
„L
PAGE PLAT ,AND THAT I(WE) HEREBY
SERVED BY INDIVIDUAL SEPTIC TANK
REGULATIONS DESCRIBED BY SUBDIVISION
ORDIANCE OF BEAUFORT
Co
/
ADOPT THIS PLAN OF SUBDIVISION
ry
COUNTY. AND THE
NUMBER OF LOTS HAS NOT INCREASED AND THE
,�•
AS REQUIRED BY THIS ORDINANCE,
ESTABLISH THE MINIMUM BUILDING
X51
o°
; A65
A64
64a` Wo WETLANDS "'
- o �`(2, 01 77 AC °"`
�• E I P,
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/ a
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ACC
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Q `.`
n
COASTAL �
PC E. SL 1 DE 38 -5
BACK REF: PC E. SLIDE 1 -5
p 4
A
SHALL BE VALID FOR A PERIOD PRESCRIBED
/ O
,r �, by
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,�
��
BY CURRENT RULES AND SUBJECT TO THE
ELBERT L. BANKS
4 P
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/
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1
'REM /6} A7 �& ar ^ LAMA P 1
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OF
WILLIAM K.
S / MCLAUGHLIN
251 A73 A72 'r 52.53.00 '` NPS
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CORB CORE CORBH AMA pAMA 3"
END
NPS MIS 50.02'00 "E
CORE t 35 20. �' 5.69' \ ,° No Al / 141 cb
^^ COR DR ORBH N NP 7) 8 ps 1ETLANDS �O ry
• 6' 10.6352 AC ,4
536.14'06 "W t NIS i1 yh / X21 /
7'90' NP 20.00' / PROPERTY OF DEWARD H. &
POINT ALONG /
THE WATER'S EDGE S32 ?14'07 "W Is y ' LORENE P. SMITH / AREA OF 23.66' NPSN PS CONCERN.EMEAS MEASURED 75' DB 91 1 . PG 290 (MAP)
A
FROM EDGE OF WATER /
A ^^ P 'PERMIT ZONE'
N LICp R IP CC(320) / / WILLIAM R. /KENNETH H.
N. 67' 53 "E CARPENTER
1 M,9.6', DB�9910 SPG iii'
/ DB 1515. PG 819
7
" GAZEBO EDGE OF W4
50 0 100 200 '� REVISED 9 -12 -07 (COUNTY HEALTH CERT)
I REVISED 9 -13 -07 (SUED APPROVAL CERT)
CHIC SCALE- 1" • 100' ^^ REVISED 1 -27 -12 (ACCESS EASEMENT LOTS E AND F. DETAIL)
REVISED 2 -20 -12 (ACCESS EASEMENT LOT D. SURVEY CERT)
REVISED 1 -25 -13 (REDUCED NUMBER OF LOTS)
OWNERSHIP AND D I
ED CA T
6.
7.
8.
9.
404 WETLANDS (I
404 WETLANDS (
COASTAL WETLANI
UPLANDS 1: 0.01
UPLANDS 2: 0.01
LOT A: 1.6745
LOT B: 1.3189
LOT C: 1.9377
LOT D: 4.1043 .
JURISDICTION OF BEAUFORT COUNTY, IMPROVEME S PERMIT. THIS rERTIFICATION
DOES NO ONSTITUTE "BLYqKET APPROVAL"
OF ALL T 1 E SU 410N.
)PROVED•DTB %
ATE' 1 -26-12 BE ORT COU Y H T DIRECTOR
OWN R(S) 0 DESIGNEE W 0 S ALL BE AN
AUTHORIZED AGE F jHEL TE DATE
,ALE: 1" • 100' DATE �'��i /-� 3
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ION
BEAUFORT COUNTY HEALTH CERTIFICATION
SUBDIVISION APPROVAL CERTIFICATION
I 0 N
I (WE) CERTIFY THAT I AM (WE ARE)
THE OWNER(S) OF THE PROPERTY
SHOWN
I HEREBY CERTIFY THAT THE SUBDIVISION
ENTITLED LOT 6, RIVER WALK DIVISION
THIS PLAT CREATES A RECOMBINATION OF
AND DESCRIBED HEREON
CONSISTS OF EIGHT (8) LOTS, SEVEN (7) OF
EXISTING PARCELS OR PORTIONS OF EXISTING
WHICH WAS CONVEYED TO ME (US)
BY DEED RECORDED IN BOOK SEE
WHICH ARE SPECIFIED AS BUILDING LOTS
PARCEL Of LANG AND IS NOT SUBJECT TO
PAGE PLAT ,AND THAT I(WE) HEREBY
SERVED BY INDIVIDUAL SEPTIC TANK
REGULATIONS DESCRIBED BY SUBDIVISION
ORDIANCE OF BEAUFORT
REGISTRY
ADOPT THIS PLAN OF SUBDIVISION
SYSTEMS EACH BUILDING LOT WAS
PROVIDED WITH PROPER APPLICATION,
COUNTY. AND THE
NUMBER OF LOTS HAS NOT INCREASED AND THE
N.C.
AS REQUIRED BY THIS ORDINANCE,
ESTABLISH THE MINIMUM BUILDING
EVALUATION AND IMPROVEMENTS
RESULTANTS LOTS ARE EQUAL TO OR EXCEEDS
LINES, AND DEDICATE ALL DRAINAGE
PERMIT FOR AN INDIVIDUAL SEPTIC TANK
THE REOUIREMENTS OF BEAUFORT COUNTY.
WAYS AND OTHER OPEN SPACES TO
SYSTEM PURSUANT TO THE GENERAL
PUBLIC OR PRIVATE USE AS NOTED.
STATUTES NORTH CAROLINA AND
FURTHER, I (WE) CERTIFY THAT THE
A
SHALL BE VALID FOR A PERIOD PRESCRIBED
LAND AS SHOWN HEREON IS WITHIN
BY CURRENT RULES AND SUBJECT TO THE
JJ J
SUBDIVISION ADMINISTtfATOR DATE
THE SUBDIVISION REGULATION THE
SET FORTH ON THE
JURISDICTION OF BEAUFORT COUNTY, IMPROVEME S PERMIT. THIS rERTIFICATION
DOES NO ONSTITUTE "BLYqKET APPROVAL"
OF ALL T 1 E SU 410N.
)PROVED•DTB %
ATE' 1 -26-12 BE ORT COU Y H T DIRECTOR
OWN R(S) 0 DESIGNEE W 0 S ALL BE AN
AUTHORIZED AGE F jHEL TE DATE
,ALE: 1" • 100' DATE �'��i /-� 3
V Y T I(• CA Y.I. J4 6 r- o G fc1 q 1
0
V Y V co
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0
bO3_ q-7- APR 15 2013 ci
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