Chleborowicz, Arthur

C CAMA /.'�.] DREDGE & FILL
GENERAL PERMIT
New ❑Modification ❑Complete Reissue
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❑Partial Reissue
No. 73196 A B jfC D
Previous permit #
Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality —,�y�
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC f S ! —
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Applicant Namet C� C1(1Cd1N I �2 Project Location: County
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❑ PWS:
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Agerd or licant Printed Name
Si ture * Please read compliance statement on back of permit
Application Fee(s) V Check #
Permit Officer's Printed Name ft
.r
Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that 1) prior to undertaking any activities authorized by this permit, the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s) .
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar - Pamlico River Basin Buffer Rules J Other:
Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-6481) or the
Wilmington Regional Office (910-796-7215) for more information on how to complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ 1-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves: Carteret, Craven, Onslow -
North of New River Inlet- and Pamlico
Counties)
Elizabeth City District
401 S. Griffin St.
Ste. 300
Elizabeth City, NC 27909
252-264-3901
Fax: [phone]
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
(Serves: Beaufort, Bertie, Hertford, Hyde,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext.
Wilmington, NC 28405-3845
910-796-7215
Fax: [phone]
(Serves: Brunswick, New Hanover,
Onslow - South of New River Inlet -
and Pender Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/ 17

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 14�-/2 /—//- 41 /r C�/L/,F- /30/20 !ter/ �Z
Mailing Address:
Phone Number: S - Z
Email Address:
rt ��
I certify that I have authorized /Y
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: �y /2 /Z/j"Z!, I,0."'T
g'�t L/c- l �/L � /�/ �G l / '�— /,Z' & /A--o 9 U rr l 40--E
at my property located at
in County.
I furthermore certify that l am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature
c z
Print or Type Name
Title
Date
A.L10 aHW'INoa
gIOZ � X l\ON
This certification is valid through / I
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