20170847 Ver 1_CAMA Application_20170707

Coastal Management
ENVIRONMENTAL QUALITY
July 5, 2017
MEMORANDUM
TO:
RECEIVED
JUL 0 7 20V
_j)E�A.L���Uw
-S"MW8WEEW1TW1
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
BRAXTON C. DAVIS
Director
2 0 1 7 0 8 4 7
Karen Higgins, Compliance and Permitting Unit Supervisor
DWR - Water Quality Program
FROM: Doug Huggett, Major Permits Coordinator
c/o Gregg Bodnar, Assistant Major Permits Coordinator
Division of Coastal Management
SUBJECT: CAMA/DREDGE & FILL Permit Application Review
Applicant: John and Pamela Jelich
Project Location: 111 Wood Duck Drive, Currituck County
Proposed Project: Bulkhead
Please indicate below your agency's position or viewpoint on the proposed project and return this
form by 07/26/17 to 400 Commerce Avenue, Morehead City. NC 28557 (fax: [phone]).
If you have any questions regarding the proposed project, please contact Ron Renaldi at (252) 264-
3901. When appropriate, in-depth comments with supporting data are requested.
REPLY: This agency has no objection to the project as proposed.
This agency has no comment on the proposed project.
This agency approves of the project only if the recommended changes are
incorporated. See attached.
This agency objects to the project for reasons described in the attached
comments.
SIGNED DATE
--�`Nothing Compares -- ,
State of North Carolina I Environmental Quality I Coastal Management
401 S. Griffin St., Ste 300 1 Elizabeth City, NC 27909
252-264-39011252-331-2951 [fax]

DIVISION OF COASTAL MANAGEMENT
FIELD INVESTIGATION REPORT
1 . APPLICANT'S NAME: John & Pamela Jelich
2. LOCATION OF PROJECT SITE: 111 Wood Duck Drive (SR#1 501), Lot 20 within Belle
Isle subdivision, Currituck, Currituck County, adjacent to the mouth of a man-made canal
that leads to Coinjock Bay.
Photo Index - 2006: 194-7111 (L 20)
Lat/Long: 36.4217600 N, -75.9713130 W
3. INVESTIGATION TYPE: CAMA/Dredge & Fill
4. INVESTIGATIVE PROCEDURE: Dates of Site Visit - 6/8/2017
Was Applicant Present - Yes
5. PROCESSING PROCEDURE: Application Received Complete - 6/21/2017
Office - Elizabeth City
6. SITE DESCRIPTION:
(A) Local Land Use Plan - Currituck County
Land Classification from LUP - Limited Service Area & Conservation
(B) AEC(s) Involved: Public Trust Area (PTA), Estuarine Waters (EW), and Estuarine
Shoreline (ES)
(C) Water Dependent: Yes
(D) Intended Use: Private Residential
(E) Wastewater Treatment: Existing - None (Vacant lot)
Planned - n/a
(F) Type of Structures: Existing - Riprap
Planned - Bulkhead
(G) Estimated Annual Rate of Erosion: None
Source - Applicant
7. HABITAT DESCRIPTION: [AREA, square feet (ft2)]
FILLED DISTURBED
(A) Shallow Bottom PTA, EW AEC's 1 ±612 ft2
(B) Estuarine Shoreline AEC
±2,940 ft2
(D) Total Area Disturbed: ±3,552 ft2 (0.082 acres)
(E) Primary Nursery Area: No
(F) Water Classification: SC Open to Shellfishing: No
8. PROJECT SUMMARY: The applicant proposes to construct a bulkhead waterward I of a
riprapped shoreline that will tie into an adjoining bulkhead and boat ramp return wal.
Proiect ettina
The site of the proposed development is a vacant Lot addressed as 111 Wood Duck Drive
(SR#1 501), Lot 20 within Belle Isle subdivision, Currituck, Currituck County, adjacent to the mouth of
a man-made canal that leads to Coinjock Bay and ultimately the Currituck Sound.

"till
JOHN W. JELICH, III
113 WOOD DUCK DRIVE
CURRITUCK, NORTH CARILINA 27929
TEL: [phone]
May 5, 2017
Mr. Ron Renaldi
Field Representative
NC Division of Coastal Magnagement
NC Department of Environmental Quality
401 S. Griffin St., Ste 300
Elizabeth City, N.C. 27909
Re: I I I Wood Duck Drive, Currituck, NC 27929, CAMA Major Permit
Dear Renaldi:
Thank you for emailing me the MP I standard application form on February 20, 2017. 1 am
enclosing the completed MP I application for the CAMA major permit for the above -referenced
property which my wife, Pamela and I own, which is adjacent to our home, along with the
necessary documents attached thereto. I am also enclosing a check to cover the costs of the
permit. Upon your review of same, please let me know if there is any additional information that
you would need from me in order to process the permit. I had originally hired a contractor to do
the work about a year and a half ago, but he never applied for the permit. At this point I will
either proceed with the project myself or I may engage the services of a contractor at a later date.
The proposed project at I 11 Wood Duck Drive will consist of installing a new wooden
bulkhead, aligning itself with both neighboring bulkheads (ours and the Connell's) at their
furthest points outward into the canal. We will then install 250 cubic yards of sand backfill
behind the new bulkhead to re-establish yard lost due to erosion over the past years. The
construction of this new bulkhead will not obstruct any navigable waterways nor will the fill
being installed come in contact with any coastal wetlands, marsh, submerged aquatic vegetation,
shell bottom, or any other type of wetlands.
The construction of the bulkhead along with the backfilling will be done utilizing a bobcat
track loader, with either a backhoe attachment and bucket, and/or a separate backhoe. The 2� 30*
disturbance area is for proper dead man installation for bulkhead strength. We will also tie into
our property to the west and will add a new return wall of 10.64 ft. to the Connell's property line
to the east, so as not to disturb the existing boat ram wall to the east. After completion of the
project, seed grass will be spread/raked into the top two inches of the soil to help with any wind
erosion that might occur. I trust that you will find this in order.
S*erely,
JoVn'.-W. Jelich, ffil"
Enclosures

gem mr-1
APPLICUIDN for
Major Development Permit
(last revised 12/27/06)
0`3100
AIR IF, "Orif
ppqo3am
North Carolina DIVISION OF COASTAL MANAGEMENT
1. Primary Applicantl Landowner Information
Business Name
Project Name (if applicable)
Business Name
W
Applicant 1: First Name
MI
Last Name
:73-0 �' ,
�� �J ,
Ml
Applicant 2: First Name
Ml
Last Name
PO Box
:]C4
City
State
If additional applicants, please attach an additional page(s) with names listed.
----T
Mailing Address
PO Box
city
state
V j�
Contractor #
+
Street Address (if different from above)
ZIP
Country
Phone No.
FAX No.
2--7 q 2- cl�
(ASA
647 - 0 O.Z ext.
Street Address (if different from above)
city
State
ZIP
Email V"'
�k Ir
2. AgentlContractor Information
Business Name
Agent/ Contractor 1: First Name
Ml
Last Name
Agent/ Contractor 2: First Name
Ml
Last Name
Mailing Address
PO Box
:]C4
City
State
ZIP
Phone No. 1
ext.
Ph one No. 2
ext.
FAX No.
Contractor #
Street Address (if different from above)
city
State
ZIP
Email
<Form continues on back>
252-808-2808 — 1-808-4RCOAST :. www,nccoasta1wanaqement.ne1,.

Rece'Ved
Form DCM MP -1 (Page 2 of 4)
APPLICATION for
Major Development Permit
3. Project Location LJ ki I V1 -L k,,
County (can be multiple)
Street Address
State Rd. #
!+ i
ip I&
d. Approximate elevation of tract above NHW (normal high water) or
Subdivision Name
NWL (normal water level)
State
Zip
a. Vegetation on tract
r
f. Man-made features and uses now on tract
_7
Phone No.
Lot No.(s) (if many, attach additional page with list)
ext.
I I I I
a. In which NC river basin is the project located?
b. Name of body of water nearest to proposed project
ck
c. Is the wate�body identified in (b) above, natural or manmade?
d. Name the closest major water body to the proposed project site.
RNatural OManmade OUnknown
1. Is the proposed project located in a National Registered Historic District or does it involve a []Yes NNo MNA
a. Is proposed work within city limits or planning jurisdiction?
f. If applicable, list the planning jurisdiction or city limit the proposed
NYes ONo
work falls within.
(Z' '_'4A + Ll
4. Site Description
a. Total length of shoreline on the tract (ft.)
b. Size of entire tract (sq.ft.)
3
!+ i
c. Size of individual lot(s)
d. Approximate elevation of tract above NHW (normal high water) or
NWL (normal water level)
(If man; lot size;, pleas� attach additional page with a list)
EINHW or 9NWL
a. Vegetation on tract
f. Man-made features and uses now on tract
N ��
g. Identify and describe the existing land uses adbacen to the proposed project site.
Z'
h. How does local government zone the tract?
I. Is the proposed project consistent with the applicable zoning?
rA Z., 0-
(Attach zoning compliance certificate, if applicable)
5&Yes []No [INA
j. Is the proposed activity part of an urban waterfront redevelopment proposal? []Yes CONo
k. Hasa professional archaeological assessment been done for the tract? If yes, attach a copy. E]Yes IRNo EINA
If yes, by whom?
1. Is the proposed project located in a National Registered Historic District or does it involve a []Yes NNo MNA
National Register listed or eligible property?
<Form continues on next page.,,,
2 5 2 - 8 0 B-28 0 8 : � 1-883-4RCOAST :: www.nccoastaimanagement.net
-2

Form DCM MP -1 (Page 3 of 4)
APPLICATION for
' :�� 0 1 20"i
�1:!q bA Major Development Permit
in A A r- on
m. (1) Are there wetlands on the site? UD U IVI t Lo E]Yes SfNo
(!I) Are there coastal wetlands on the site? []Yes 13No
(iii) If yes to either (1) or (!I) above, has a delineation been conducted? 0Yes []No
(Attach documentation, if available)
n. Describe existing wastewater treatment facilities.
o. Describe existing drinking water supply source.
N I /A
p. Describe existing storm water management or treatment systems.
5. ActIvities and Impacts
a. Will the project be for commercial, public, or private use? ElCommercial E]Public/Government
P�' t' V "—�- g]Private/Community
b. Give a brief description of purpose, use, and daily operations of the project when complete. io CL r%
6
- 6,-,- L' 'v k C
k* Y'19 V- I P. -e^ -3-P 0"i
V%,
y1'a 'r ';J z. i- k k
c. Describe the proposed construction methodology, types of construction equipment to be used during construction, the number of each type
of equipment and where it is to be stored.
-VIt, e.
e, jN -�; +'�—
d. List all development activities you propose.
�J,is A-ct tk �33 'it -,t- --�Cr yle—w '--CCLzv\ AZ
rX
a. Are the proposed activities maintenance of an existing project, new work, or both?
N;2� \j" ��J Z' i - �-'
f. What is the approximate total disturbed land area resulting from the proposed project? HSq.Ft or OAcres
4 0
g. Will the proposed - project encroach on any public easement, public accessway or other area E]Yes RNo []NA
that the public has established use of?
h. Describe location and type of existing and proposed discharges to waters of the state.
N/A
1. Will wastewater or stormwater be discharged into a wetland? 0Yes S]No CINA
If yes, will this discharged water be of the same salinity as the receiving water? []Yes []No [INA
j. Is there any mitigation proposed? []Yes &No CINA
If yes, attach a mitigation proposal.
""�r
S � "v e - C' - S. k 5 i -, " Iq �
9
<Form continues on back>
252-808-2808 :.- 1-888-4RCOAST :: www.riccoastallmanagIament.net
04-

-6
Form DCM MP -1 (Page 4 of 4) APPLICATION for
Major Development Permit
6. Additional Information DCM-EC
In addition to this completed application form, (MP -1) the following items below, If applicable, must be submitted in order for the application
package to be complete. Items (a) — (0 are always applicable to any major development application. Please consult the application
instruction booklet on how to property prepare the required items below.
a. A project narrative.
b. An accurate, dated work plat (including plan view and cross-sectional drawings) drawn to scale. Please give the present status of the
proposed project. Is any portion already complete? If previously authorized work, clearly indicate on maps, plats, drawings to distinguish
between work completed and proposed.
c. A site or location map that is sufficiently detailed to guide agency personnel unfamiliar Wth the area to the site.
d, A copy of the deed (with state application only) or other instrument under which the applicant claims title to the affected properties.
a. The appropriate application fee. Check or money order made payable to DENR.
f. A list of the names and complete addresses of the adjacent waterfront (riparian) landowners and signed return receipts as proof that such
owners have received a copy of the application and plats by certified mail. Such landowners must be advised that they have 30 days in
which to submit comments on the proposed project to the Division of Coastal Management.
Name C_�A + �- V Y% 'r\ Phone No.
Address o­� k.�; t) r�A � �> r. 2--7 ct:z q (IF -133) �+ L 3
Name DLtv"a -i- Phone No.
Address '7 '-12- 9
Name Phone No.
Address
g. A list of previous state or federal permits issued for work on the project tract. Include permit numbers, permittee, and issuing dates.
h. Signed consultant or agent authorization form, if applicable.
1. Wetiand delineation, if necessary. �4 11 14,
j. A signed AEC hazard notice for projects in oceanfront and inlet areas. (Must be signed by property owner)
k. A statement of compliance with the N.C. Environmental Policy Act (N.C.G.S. 11 3A 1 -10), if necessary. If the project involves expenditure
of public funds or use of public fends, attach a statement documenting compliance with the North Carolina Environmental Policy Act.
7. Certification and Permission to Enter on Land
I understand that any permit issued in response to this application will allow only the development described in the application.
The project will be subject to the conditions and restrictions contained in the permit.
I certify that I am authorized to grant, and do in fact grant permission to representatives of state and federal review agencies to
enter on the aforementioned lands in connection with evaluating information related to this permit application and follow-up
monitoring of the project.
I further certify that tl�le information provided in this application is truthful to the best of my knowledge.
'7 Print Name
Date
Signature
Please indicate application attachments pertaining to your proposed project.
IRDCM MP -2 Excavation and Fill Information EIDCM MP -5 Bridges and Culverts
ODCM MP -3 Upland Development
[IDCM MP -4 Structures Information
252-808-2808 — 1-888-4RCOAST -.: www.necoastaimanagement.net

Received
Form DCM MP -2
�i IN' 2 11 � Ill 17
EXCAVATION and FILL DMEC
(Except for bridges and culverts)
Attach this form to Joint Application for CAMA Major Permit, Form DCM MP -1. Be sure to complete all other sections of the Joint
Application that relate to this proposed project. Please include all supplemental information.
Describe below the purpose of proposed excavation and/or fill activities. All values should be given In feet.
1. EXCAVATION This section not applicable,
a. Amount of material to be excavated from below NHW or NWL in b. Type of material to be excavated.
cubic yards.
c. (1) Does the area to be excavated include coastal wetlands/marsh d. High -ground excavation in cubic yards.
(CW), submerged aquatic vegetation (SAV), shell bottom (S13),
or other wetlands (WQ? If any boxes are checked, provide the
number of square feet affected.
oew OSAV CISB
[:]WL [:]None
(!I) Describe the purpose of the excavation in these areas:
2. DISPOSAL OFEXCAVATED MATERIAL UThis section not applicable
a. Location of disposal area. b. Dimensions of disposal area.
C. (1) Do you claim title to disposal area? d. (I) Will a disposal area be available for future maintenance?
C]Yes []No FINA []Yes 0No DNA
(I!) If no, attach a letter granting permission from the owner. (ii) If yes, where?
a. (I) Does the disposal area include any coastal wetlands/marsh f. (I) Does the disposal include any area in the water?
(CW), submerged aquatic vegetation (SAV), shell bottom (SB), []Yes []No EINA
or other wetlands (WQ? If any boxes are checked, provide the (11) If yes, how much water area is affected?
number of square feet affected.
[]CW C]SAV EISB
EIWL E]None
(!I) Describe the purpose of disposal in these areas:
252-808-2808 . 1-888-4RCOAST :* www.riccoastalmanagement.net revised: 12126106
­­' ----------- ­­ ­.­ ....... . ... . ...... . ­_ __.'
Access
Other
Channel
(NLW or
Canal
Boat Basin
Boat Ramp
Rock Groin
Rock
Breakwater
(excluding
shoreline
NWL)
stabilization)
Length
Width
Avg. Existing
NA
NA
Depth
Final Project
NA
NA
Depth
1. EXCAVATION This section not applicable,
a. Amount of material to be excavated from below NHW or NWL in b. Type of material to be excavated.
cubic yards.
c. (1) Does the area to be excavated include coastal wetlands/marsh d. High -ground excavation in cubic yards.
(CW), submerged aquatic vegetation (SAV), shell bottom (S13),
or other wetlands (WQ? If any boxes are checked, provide the
number of square feet affected.
oew OSAV CISB
[:]WL [:]None
(!I) Describe the purpose of the excavation in these areas:
2. DISPOSAL OFEXCAVATED MATERIAL UThis section not applicable
a. Location of disposal area. b. Dimensions of disposal area.
C. (1) Do you claim title to disposal area? d. (I) Will a disposal area be available for future maintenance?
C]Yes []No FINA []Yes 0No DNA
(I!) If no, attach a letter granting permission from the owner. (ii) If yes, where?
a. (I) Does the disposal area include any coastal wetlands/marsh f. (I) Does the disposal include any area in the water?
(CW), submerged aquatic vegetation (SAV), shell bottom (SB), []Yes []No EINA
or other wetlands (WQ? If any boxes are checked, provide the (11) If yes, how much water area is affected?
number of square feet affected.
[]CW C]SAV EISB
EIWL E]None
(!I) Describe the purpose of disposal in these areas:
252-808-2808 . 1-888-4RCOAST :* www.riccoastalmanagement.net revised: 12126106
­­' ----------- ­­ ­.­ ....... . ... . ...... . ­_ __.'

'Received
Form 0CM MP -2 (Excavation and Fill, Page 2 of 2)
3. SHORELINE STABILIZATION 0 This section not applicable
(If development is a wood groin, use MP -4 - Structures) WMIC
a. I Ype OT snoreiine sEaunization:
NBulkhead ORiprap OBreakwater/Sill OOther:
C. Average distance waterward of NHW or NWL:
e. Type of stabilization material:
V4 �-' zt�' 1�
g. Number of square feet of fill to be placed below water level.
Bulkhead backfill &c� Riprap
Breakwater/Sill Other
I. Source of fill material.
Le,119M. -1r-r
Width: t—vies
d. Maximum distance waterward of NHW or NWL:
t � 0
f. (I) Has there been shoreline erosion during preceding 12
months?
[:]Yes JgNo [INA
(ii) If yes, state amount of erosion and source of erosion amount
information.
4 11
h. Type of fill material.
4. OTHER FILL ACTIVITIES 10 This section not applicable
(Excluding Shoreline Stabilization)
a. (I) Will fill material be brouaht to the site? OYes ONo ONA b, (I) Will fill material be placed in coastal wetlands/marsh (CW),
If yes,
(ii) Amount of material to be placed in the water
(iii) Dimensions of fill area
(Iv) Purpose of fill
submerged aquatic vegetation (SAV), shell bottom (bb), or
other wetlands (WL)? If any boxes are checked, provide the
number of square feet affected.
[-]CW EISAV _ EISB
OWL ONone
(ii) Describe the purpose of the fill in these areas:
15. GENERAL I
a. How will excavated or fill material be kept on site and erosion b. What type of construction equipment will be used (e.g., dragline,
controlled? backhoe, or hydraulic dredge)?
FotW.k\ -4'1-�-il-t�k�l h�- �A�-- A-
C. (I) Will navigational aids be required as a result of the project?
Oyes [SNo [:INA
(ii) If yes, explain what type and how they will be implemented.
Date
Project Name
d. (1) Will wetlands be crossed in transporting equipment to project
site? OYes [ONo [INA
(ii) If yes, explain steps that will be taken to avoid or minimize
environmental impacts.
Applicant Name
— —7-c' vt
Applica Signature
J -
252-808-2808 : 1-888-4RCOAST n www.nccoastaimanaqement.net revised: 12126106
.......... .... .. — . ........ . . . ......

DATE: MUST SEND CERTIFIED MAIL/
RETURN RECEIPT REQUESTED
NAME:
ADDRESS:
CITY: ST ZIP
RE: {PROJECT NAME)
To Whom It May Concern:
This correspondence is to notify you as a riparian property owner that is applying for
pan
which is adjacent to your property. A copy of the application and project'drawing(s) is enclosed for your review. Ifyouhaveno
objections to the proposed activity, please mark the appropriate statement below and return to:
as soon as possible.
(insert' natne�d spo'n.s- I ble �partyl
If no comments are received within 30 days of receipt of this notice, it will be considered that you have no comments or objections
regarding this project. If you have objections or comments, please mark the appropriate statement below and send your
correspondence to the NC Division of Coastal Management. Contact information for DCM offices is available at
www.nccoastalmangement.neY,contact—dcm.htm or by calling 1-888-4RCOAST. If you have questions about the project, please do not
hesitate to contact me at
Sincerely,
INSERTNAME
I have no objection to the project as described. I have objection(s) to the project as described.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift 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.)
I do wish to waive the 15'setback requirement. I do not wish to waive the 15' setback requirement.
'77'
Print Name Signature of AdjacenO�opiirtybwner Date
Mailing Address Phone Number

DATE:
NAME:
ADDRESS:
CITY: ST ZIP
WA
To Whom It May Concern;
MUST SEND CERTIFIED MAIIJ
RETURN RECEIPT REQUESTED
�PROJECT NAME)
This correspondence is to notify you as a riparian property owner that is applying for
(ini6rt pro er ame or company)
0 ty owner,n
a CAMA Major permit to
(Insert project desc,0066h)
on property located at
which is adjacent to your property, A copy of the application and project drawing(s) is enclosed for your review. If you have no
objections to the proposed activity, please mark the appropriate statement below and return to:
as soon as possible.
If no comments are received within 30 days of receipt of this notice, it will be considered that you have no comments or objections
regarding this project, If you have objections or comments, please mark the appropriate statement below and send your
correspondence to the NC Division of Coastal Management. Contact information for DCM offices is available at
www.nccoastalmangemen ' t.neYcontact—dcm.htm or by calling 1-888-41RCOAST. If you have questions about the project, please do not
hesitate to contact me at (insertlphbn6 humberl.
Sincerely,
INSERT NAME
1 have no objection to the project as described. I have objection(s) to the project as described.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a minimum distance of 15'from my area
of ss unless waived by me. (If you wish to waive the setback, you must Initial the appropriate blank below.)
I do wish to waive the 15'setback requirement, I do not wish to waive the 15' setback requirement.
Print Name Signature of Adjacent Property Owner/ D6te
-71
7,!EZ
Mailing Address Phone Number

MAJOR PERMIT FEE MATRIX
Applicant: JOHN & PMEIA JKLICH
Selection
Development Type
Fee
DCM %
DWQ %
(14300 1601 435100093 1625 6253)
(24300 1602 435100095 2341)
1. Private, non-commercial
E]
development that does not
$250
100%($250)
0%($0)
involve the filling or
excavation of any wetlands
or open water areas:
11. Public or commercial
development that does not
$400
100%($400)
0%($0)
involve the filling or
excavation of any wetlands
or open water areas:
Major Modification to a
$250
100%($250)
0%($0)
CAMA Major permit
I 11. For development that
involves the filling and/or
excavation of up to 1 acre
of wetlands and/or open
water areas, determine if A,
B, C, or D below applies:
III(A). Private, non-
commercial development, if
$250
100%($250)
0%($0)
General Water Quality
Certification No. 3900 (See
attached) can be applied:
III(B). Public or commercial
E:1
develo ' pment, if General
$400
100%($400)
0%($0)
Water Quality Certification
No. 3900 (See attached)
can be applied:
III(C). If General Water
Quality Certification No.
$400
60%($240)
40%($160)
3900 (see attached) could
be applied, but DCM staff
determined that additional
review and written DWQ
concurrence is needed
because of concerns
related to water quality or
aquatic life:
III(D). If General Water
Quality Certification No.
$400
60%($240)
40%($160)
3900 (see attached) cannot
be applied:
IV. For development that
involves the filling and/or
$475
60%($285)
40%($190)
excavation of more than
one acre of wetlands and/or
open water areas:

NC Division of Coastal Management
w Cashier's Official Receipt
Received From:
Permit No.:
Applicant's Name:
Project Address:
-*T
3904Q� C D
<7
Date: 20
$
Check No.:
County:
Please retain receipt for your records as Proof of payment for Permit issued.
Signature of Agent or Applicant: /,7w,,, -i 1
Signature of Field Representative:
- - - - - - - - - - - - - - - -
Date:
Date:

k
qj
\-A V 6v
rA \I 1,
P V U 0
03-WDG
A01 1: Vv!;�
POA10398
F.
\1 --.) .' I 'or
Y? JA �A "D '"')

I
lod
W -,A -8,(A 0 0
�LA k�4�$,Aq
03-WO(I
AN i g J�p;