Barefield, David

❑ CAMA / ❑ DREDGE & FILL ( No. 75719 A B C D
GENERAL PERMIT J �( LPrevious permit#
❑New ❑Modification ❑Complete Reissue ❑Partial Reiss a Date previous permit issued
As authorized by the State of North Carolina, Department of EnvironmentahQouality
and the Coastal Resou ces Commission in an area of environmental conc rn pursuant to 15A NCAC
❑ Rules attached.
Applicant Name f ,1iA N. �(1 _-' i6 Project Location: County_ (,C.
Address " ' L. l . > j, ! -L / /1 Street Address/ State Road/ Lot #(s)_
City A, t`. State � ZIP (: / ? '
Phone #,(,3 �� �- V _Mail -' Subdivision
1 7 '/t /
Authorized Agent i ` - ` ' ` City ✓ (/ _ ZIP
Affected a�N \qpW r DES DP't - Phone# ( iL, River Basin
AEC(s): OOEA �HHF ❑UBA ❑N/A Adj. Wtr. Body rc 3 (nat /man unkn)
❑ PWS:
ORW: yes / no PNA yes / �io� Closest Maj. Wtr. Body— -
Type of Project/ Activity
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A building permit may be required i
( Note Local Planning jurisdiction).,
Notes/ Special Conditions
d
or Applicant Printed Name
Signature r+Please read compliance state entif,onbacko permit'["'
❑ See note on back regarding River Basin rules.
)(titer's Printed Naine
re /
PP

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address: 3J 6'7 N `tab/�t
Phone Number: _ ZGJ 2. l 4 c 33 Ss
Email Address:
I certify that I have authorized
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 located at v 3 14
in anrcr{County.
CI w L Dr"
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.
Title
o l Date
This certification is valid through i 2 l'31--l—LL

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