55162_CROMWELL, MARK_20100507 (2)

12CAMA / D EDGE & FILL
kG E N ERMIT
RECE E
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Previous permit #
New ification ❑Complete Reissue 0Partial Reissue Date previous permit issued
As authorized by the ate of North Carolina, Department of Environment and
AUG 15 201i
and the Coastal Resources Commission in an area of environmental codncern puns
Applicant Name !K A,� f f �j L c -
Address 9
city �t , State ' f ZIP '�
Phone # (� P��J rax #
Authorized Agent
Affected
AEC(s):
❑ CW
❑ OEA
iEW -PTA °ES ❑ PTS
HHF ❑ IH ❑ UBA ❑ N/A
PWS: 0 FC:
ORW: Yes / .no j PNA yes / no. Crit.Hab, yes / ;f?o1'.
Natural Resources j ; �f',
uant to I SA NCAC ���'
i + Rules attached.
g DCM-MHD CITY ,n r—
Project Location: County r'
Street Address/ State Road/ Lot #(s) 'Ts' -2 ) ',-
Subdivision
City tkklZIP°
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Phone # River Basin "' - ;�. � i
Adj. Wtr. Body ��'/ /man /unknj
Closest Maj. Wtr. Body—JalI- e--'emP
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Agent br App'licani pf intact Nar}ie
Signat ' ¢ * Please read compliance statement'on ba of permit **
Application Fee(s) Check #
Permitoffice 's nat re
Issuing Date Expiry on Date
kJT!Y C n 71/14
Locale ing jurisdictwn Rover File Name