General Permits (4966)

�as�tvlsa / OF.F-DGE & FILL
GENERAL PERMIT Previous permit #
❑New ❑Modification rE�Complete Reissue El Partial Reissue t'
Date previous permit issued j /C/
As authorized by the State of North Carolina, Department of Environment and Natural Resources 4-1
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and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC _} a
Applicant
Addre;s
CI t State> .. ...ZIP-- b
Phone# €-� �#(-)
Authorized Agent'— "
Affected cw L] ew i PTA ❑ es ❑ PTs
AEC(s): OFA O HHF "O IH ❑ USA Q N/A
❑ PWS: ❑ FC:
ORW: yes / no PNA yes / no Crit.Hab, yes / no
Type of Project/ Activity
Pier (dock) len h
Platf
Fing
mom
Groi
Bulk)
Basin
Boat
Boad
Beacl-
Other
Shore)
'SAv-
Sandb
Morat
Photos
Waive
CJRules attached.
Project Location: County
Street Address/ State Road/ Lot #(s)
1
-e
Subdivision
City - NJy~' (. *J.. (.:.3.�� ZIP
Phone # ( River Basin
Adj. Wtr. Body'.f nat,'man
Closest Maj. Wtr. Body` t ;fJ
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(Scale: %3t .i/ 14— 1
number
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-nax distance offshore
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A building permit may be required by:
❑ Notes/ Special Conditions See note on back regarding River Basin rules.
Age -a or Applicant Printed Name
S`gnature` ece4dcorrlpllancestatement onback ofpermit
kPplication Fee(s) Check #
Permit f cer's Signature
IssyirigDate Expiration Date
LocalPlanningJurisdlction
Rover File Nam'--