43409_JACKSON, BURWELL_20051010 (2)

4' ❑C3RECGE & FILL ��
No 43409'
PERMIT'
4rCA
�E111ERAL
Previous permit #
ew ❑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 15A NCAC
/ 1-1
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�vles attached.
011i- f/o'-J,"
Applicant Name I /1 V, o
Project Location: County
Address U V1 �'/ I�; �� l�
Street Address/ State Road/ Lot #(s) � &
City�fJ!-1✓)1(;:, J ✓y State /L/(- ZIP
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Phone # (j ) �% %%% () Fax # (`)
Subdivision _
Authorized Agent _
City -� �� /-' f'J—r)r'c� _zal
Affected �CW�W �1�'A ❑ES ❑PTS
Phone # ( ) Riv//er
�) ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
AEC s :
Ad'. Wtr. BodyU .
I <-;� If < /_ (� nat; /man /unkn)
❑ PWS: ❑FC:
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ORW: yes /-_nd' PNA yes / C/rit. Hab. yes / no
Closest Maj. Wtr. Body
Type of Project/ Activity Sy i/ r/ , = �` i / �� 6 r 4 11" -% /S-
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit"
Annliran� F C) ' ('ho. L -
rerryntUtticersSignatureL11 / () / 6 , (.1 - / / // 0
-
Issuing to Expiration Date
Local Plannine Jurisdiction Rover File Name

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Michael F. Easley, Governor Charles S. Jones, Director William G. Ross Jr., Secretary
October 1.3, 2005
Burwell Jackson
270 Deer Island Rd
Swansboro, NC 28584
Attached is General Permit #43409C
In order to validate this permit, please sign all three (3) copies as indicated. Retain the white
copy for your files and return the signed yellow and pink copies to us in the enclosed, self-
addressed envelope. If the signed permit copies are not returned to this office before the initiation
of development, you will be working without authorization and will be subject to a Notice of
Violation and subsequent civil penalties.
We appreciate your early attention to this matter.
incerely,
Ryan Davenport/LSB
Coastal Management Representatives
Enclosures
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
An Equal Opportunity 1 Affirmative Action Employer— 50% Recycled 110% Post Consumer Paper

BURWELL B. JACKSON
MAxGARET G. JACKSON
240 DEER ISLAND RD. PFi• 910-326-40W
SWANSBORO, NC 28584
/2531 2217
66-7489
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09/30/2005 14:30 BHC ADMINISTRATION 4 912522473330
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09/30/2005 14:30
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BHC ADMINISTRATION 4 912522473330
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NO. 721 P02