Serigne_DredgeDisposal_SIGNED

DREDGE SPOIL DISPOSAL FORM
Project Name/address:2O(HL LIU[Kr HCh I,L"iyi County: W(.i e.h h Q
Location Address:— 111 w4d,(l n (' 66htl �A (am W �1 k N C MOOParcel #: _q l 010H n 3q�1r • 9-1 of 01-ii 4sirlu
Parcel/lot size 3.
Disposal area required (sq ft and/or acreage)
Acknowledgement of Notification
1, , am aware that the site must adhere to all state regulations
and rules regarding sediment and erosion control and water quality. And give permission for
Wltf%• ncy ftrUs
Name of Individual and Company
to dispose of their dredge material at the above stated location
Owner: KUYIGI
Print
Date: 1 IL(Q
Along with form, please provide:
Aerial of parcel/lot (County GIS)
Photo of proposed spoil site
Identified proposed spoil site
V - IM-141 ie4r�(
Signature