33540_POLK, WILLARD_20030130

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b -GENERAL 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 1200
Rules attached.
Applicant Name �, Project Location: County Y- to n S W i C� -
Address Jr 00 y- e o U-rt Street Address/ State Road/ Lot #(s) j 2
City_ r`` de.,n. State SG zip.a ozu C or�cord 6� e
Phone # a3 4-5 2 ` 3 t�
Fax # (_) Subdivision
Authorized Agent T A `�/PTA �O (r'N Tt A l ip rm; (r City C d—A � �5 \�" ZIP
❑ CW &W N ❑ ES ❑ PTS
Affected Phone # ( ) River Basin L r^ It�
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑FC: , Adj. Win Body *1 \w4r.� (nat /unkn) ,
ORW: yes /�n PNA yes / no Cit. Hab. yes / no Closest Maj. Wtr. Body l� 3
Type of ProjeW Acti%,ity r
Pier (dock) length
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MEN EM®■s®ems■ssA®��s®■.�■■®®®sv®MEN MEMO ON M MEN ME ON
MEM MEN ®®■®®®a
00 ONE NONE MEME No MEN ON No
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cubic yards_
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
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