51417_DUBOVICK, GARY & JEN_20081017 (2)

LAMA / ❑ DREDGE & FILL "
GEN PERMIT Previous permit #
New Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
-t
��} Rules att
ached.
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Applicant dProject Location: County
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Address - , Street Address/ State Road/ Lot # s
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1 ` a�� State ZIP 0 e1 I F � VA f.1)47zL I1A11.
City -_-if
Phone# ( BOO Fax # ( _) _ Subdivision
Authorged Agent City tc- 14Awk ZIP_-2
Affected
AEC(s):
ORW:
❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS
-*EA ., HHF ❑ IH Cl UBA ❑ N/A
❑ PWs: ❑ FC:
yes / no PNA yes / M' Crit.Hab. yes /
Phone # (
River Basin 4C O.7 ; 0 -
Adj. Wtr. Bod/man /unkn)
Closest Maj. Wtr. Body
AA
0 0
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Signature Please r ej d lrom
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Application Fee(s)
Permit Office ' =Signatufe