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` 'G'ENERAL PERMIT:. h
=- Previous, permit #.'. }v//7`
New.;,'- ❑Modification ' ;❑Complrete Reissue `❑Partial Reissue, _ ��Date preyious permit issued
As authorized by the State 4 ortH Carolina,; Department of,Environmental Quality,
and the-Coasfal; Resourt6s.' mission in an area of environmental concern pursuant.to 15A NCAO/r
_ files attached'
-
'ApplicantNarne ' r�%i S " Project Location: County' C
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-Address :'i�d/� 1% G� Street Address% State -Road Lot #(s)
City:Stater •ZI`F7 ' i' / ? ` G<< G✓ ��-�-1
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-Phone # ZS - Subdivisrgn
(') E-Mail
'Authorized Agent City G1%/G ZIP. ✓ -�.'
p CWFW "pTA p ES ❑ PTS Phone #, ( )_ Ri' er Basin
Affected
•❑ OEA ❑�HHF� ❑ IH ❑ UBA ❑ N/A
AEC(s): _ Adj. Wtr. Body7Body
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- ❑ PWS (' l
` ., / �o Closest Maj. Wtr
ORW: ' yes / no PNA yes
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:. Age t o plicant Printed Name Permit icy 's`Printed• ame '
" Sig",a.t�ur,e>__ P e ead compliance statement on back of permits Signature /' I r,
-"'.-Applicatio�Fee(s)• Check# fs`su6-Dafe Expiration Date
t.ip. .

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant:
Date:
General Permit #:�a�
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑.
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill.❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
252-808-2808 :: 1-888-4RCOAST :: www.nccoastaimanagement.net revised.02/03/10