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As ai.'4thbrizedby the State,of.N Environmental Qu'ality,
'6iih-Ca�6iiii�,,:D!Bpattmdpt,o�-'
r 'and the CoastaliResourcesCommission-in an area:of environmental con-erin pursu,antt6 I SA NCAC :Rule aitacted
Project Location: Co 4
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Abuilding permit may be,required by: e, See'n6te on back regarding River Basin rules., ,
Note Local Planni.n&risdiction)'
Notes/ Special Condition
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Application Fee(sj:.
statement on back of permit"
Check #
S719_naturq.:,'
Issuing Date ' X, Expiration

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" Aeeri7 ctor
to act on my Wtalf, far tfie purpose of app.1 ing for and' obtaining ail C.r+nrils permits
ne rd, for the fbitowing proposed development 71�n-714k :' new tom' l`CJ— -
- .ift my property lomted at- tol
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7 furtise"rmore azrt, y. first I:am authorized fo grant and do in facf grant parrnission to
- ' 1?iyisiasi af'Coas€af Management stati, the Local PermitOffwk and their agents €n'enter
on t*re-efiis�Wd_ 4cis in arnnec9an write evefdagag in `- «" ralafa9:iu=ff;is-
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NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: LT
Date: 1�aa
General Permit* 7 ;-�6
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