63939_Betsy B. Keller_20190315

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Application Fee(s) Check# • • Issuing bate'. • -•• ' .....Exp*ratiori'Date
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AGENT AUTO-D*REATI DON FOR CANA PERT' OT APPLDCCATOON
Name of Property Owner Requesting Permit:
Mailing Address: iti a3 S J1kA1 ?& . J r
- 501e-fiv / Ate 01-171
Phone Number: 3 31, _717 6 5'7 L
Email Address: MaIZY'5 -6"(d--61, rr. ( f�
I certify that I have authorized /'/ r�
Agent/Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property oc ted at //c57
in 1-1" r" County.
I furthermore certify that I 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:
Cad
Signature
I3t& 6• l(g,(,Ler
Printq Typ Nam
Titled 4a rrw 63'` �� --
3l l
Date
This certification is valid through I I

NC Division Coastal Mit. Habitat impact Computer Sheet
Applicant: kyiP. //‘
Date: ,JE"T / 3
General Permit#: � 'f — /3
Describe below the HABITAT disturbances for the application. All values should match the name,and units of measurement
found in your Habitat code sheet. •
TOTAL Sq. Ft. FINAL Sq. Ft. TOTAL Feet FINAL Feet
(Applied for. (Anticipated final (Applied for. (Anticipated final
DISTURB TYPE Disturbance total disturbance. Disturbance disturbance.
Habitat Name Choose One includes any Excludes any total includes Excludes any
anticipated restoration any anticipated restoration and/or
restoration or and/or temp restoration or temp impact
temp impacts) impact amount) temp impacts) . amount)
riz_ria/r- Dredge❑ Fill❑ Both ❑ Other, /Id t(f)--
Dredge❑ Fill El Both ❑ Other ❑ —�
Dredge❑ Fill❑ Both ❑ Other ❑ 'N
Dredge❑ Fill El Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other El
Dredge El Fill El Both ❑ Other ❑
Dredge❑ Fill❑ Both El Other'❑
Dredge❑ Fill.❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other El
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge El Fill❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other ❑
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