General Permits (2860)

u GAMA / u UKEOGE & FILL
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 =
Rules attached.
Project Location: County
Street Address/ State Road/ Lot #(s) `
Affected '❑ CW n EW Q PTA - n ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑FC:
ORW: yes / 4no`' PNA yes `/ no Crit.Hab. yes / no'
Subdivision -
City ZIP
Phone # River Basin
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Closest Maj. Wtr. Body
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ISBN I
Agent or Applicant Printed Name 1 PermitOffcer's Signature
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Sig �rre **Please read compliance statement on back of permit Issu�ingDate > �,� Expiration Date
Application Fee(S) = ' Check # Local Planningjurisdiction Rover File Name