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<br />5, NAMES AND ADDRESSES OF ADJOINING PROPERTY OWNERS, LESSEES, ETC., WHOSE PROPERTY ALSO ADJOINS THE WATERWAY <br /> <br />Mary L. Clark <br />850 West Branch Road <br />Blue Harbor, Maryland 21703 <br /> <br />Harry N. Hampton <br />854 West Branch Road <br />Blue Harbor, Maryland 21703 <br /> <br />(301) 585-8830 <br /> <br />(301) 585-3676 <br /> <br />6. WATERBODY AND LOCATION ON WATERBODY WHERE ACTIVITY EXISTS OR'i::fP"R-QPOSED <br />West Branch of the Haven River on Blue Harbor. <br /> <br />7. LOCATION ON LAND WHERE ACTIVITY EXISTS OR IS PROPOSED <br />ADDRESS: <br /> <br />852 West Branch Road <br />STREET, ROAD, ROUTE OR OTHER DESCRIPTIV <br /> <br />Kin Edward <br />COUNTY <br /> <br />Mar land <br />STATE <br /> <br /> <br />DYES lXINO <br />dicata the existing work on the drawings. <br /> <br />Town of Blue Harbor <br />LOCAL GOVERNING BOOY WITH JURISDICTION OV <br /> <br />8, Is any portion of the activity tor which authorization is sought <br />If answer is "Yes" give reasons, month and year the activity was c <br /> <br />9, List all approvals or certifications and denials received from other federal, irlte <br />discharges or other activities described in this application. <br /> <br />ISSUING AGENCY TYPE APPROVAL IDENTIFICATION NO DATE OF APPROVAL DATE OF DENIAL <br />Town of Blue <br /> Harbor Zoning BH25l72 6/30/82 <br />Md DNR Certification DNR258WQ 8/12/82 <br /> <br /> <br />10, Application is hereby made for a permit or permits to authorize the activities described herein. I certify that I am familiar with the information contained in <br />this application, and that to the best of my knowledge and belief such information Is true, complete, and accurate. I further certify that t possess the <br />authority to undertake the rroposed activities or I am acting as the duly euthorized agant of the applicant. <br /> <br />s/~ /r~-/ <br /> <br />SIGNATURE OF APPLICANT <br /> <br />Oct. 15, 1982 <br />DATE <br /> <br />SIGNATURE OF AGENT <br /> <br />DATE <br /> <br />The application must be signed by the person who desires to undertake the proposed activity (applicant) or it may be signed by a duly <br />authorized agent if the statement in Block 3 has been filled out and signed. . <br /> <br />18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of The United States <br />knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious or <br />fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false...fictitious or <br />fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both. <br /> <br />Do not send a permit processing fee with this application. The appropriate fee will be assessed when a permit is issued. <br /> <br />13 <br />