20150910 Ver 1_401 Application_20150903

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owwon of W~ mosaw"s
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SEP 0 3 2015 �
ftkdg% NC Z709-MO GEigR -WATE. fcESOUr:CCS
x 01 & BUFFER PERi%g177ioiG
4, (15A NCAC 02 .050218))
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2. A9MV C d PtMm to Stion
A si d aul daW co" ,of the Agent Auk letter L$ fWM can be d~Woded !were:
r at r PBrmitS/5AMPLE AGENT AtJT6i
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t1RI1ATION F4n,M0 must be aaKhed if tine Agent has s4ped this M�tkatOft fOrm.
CompW Af#fan: /was . .
Malmo .F ..o
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E -Harm! Addresv .5'�i� @ . Ca
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ft� ow ,96� s moo✓
FOM V" 1&2w li*4

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4.
etc.), rip rap, ewavftlon or dredlift below Full Pond/ Nomal Water Level ekmrAWM
and tonsuvedon access corridors. You may use the dialgram provided at the end of this
apn font►.
Attach a photqpq* of the dxwWW buftr orapoW to be sta b. (Whide a scale
of some sort- a yard stick, shovel handle, etc.)
UKation of the property (where work is to be conducted)
CO Mr: N Nearest Town:��
Subdhftim name or site addraess (indude phase/sot number): ZSi7 U-41DIL4 TAP',
Directions to site - please include road names and numbers, landmarks, eW*.
� //41MBd44- OV(Apee -q 7b GGE�ldltZ�
e-ra t ,radt bra RlG+ ✓.
i s
P"0444- rf .?. n� c. T ,ib er917 V N "A-7.
S. Die the existing land use or condition of" site at the time of this app{kstion
( msidentK Amde+ ed, ell.): #b M.F-S IM
6. PropertY site (acres): / f- 'f&Jq-
7. take/,firer/ ocm adjacent to property:
B. Deseribe Iff" sed work (Include din as to how hang of shoml m has been ,
a+roided, or why it is nec"MY): %b S'��+L4iUz A
9. WMl Wmk be o i!rorn land? [] From water?
10. Total anmmt of dot obanc a (kycluding 06 M=Nxtkm, bacidill, rip rap, Mtalning wails, etc.)
� reorertal pool I�te l j lal ��er Lam! ire 1ie'et or ate:
11. TOW MV M of disluAm se ('h►duding all devft back fin, e x
m4ation, Op rap, ruining
walls, a te.) iii the normal pod We WOV Normal Water Level and SO fM land -wwd In
feet er acsvc -5,10 r
12. Pkm describe On ver pUMon abate the normal pod like (wall Normal WOW Level and
SO fie to be inVactsd (nw nber of t»es, for In ): Nf1,'UiMW4LC
Terms —C3.1
�MWIANFWS SWIM"* (iSA NCAC 02H .05o2ci•il
A sooft" is aalda* fan ash terfamm On ours, is pvvMrd
FOIW . SSW 1040" fto&3 of 3

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