Carlisle, Sam Q II

®❑CAMA / ❑ DREDGE & FILL {.-NO. 75228 A B C D
GENERAL PERMIT Previous permit#
EJNew ❑Modification ❑Complete Reissue El Partial Reissue Date previous;permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
❑Rules attached
Applicant Name �i i � � 11 )F� ! _Project Location: County_ ' l C :
Address / ( Street Address/ State Road/ Lot #(s)
tte ZIP�u
Phone # ( )' t/' 1
Authorized Agent T�
Affected hCW DEW ❑PTA DES ❑PTS
AEC(s): ❑OEA ❑HHF ❑IH ❑USA ❑N/A
❑ PWS:
ORW: yes / no PNA yes / no
Phone # (jL)
Adj. Wtr. Body_'
Closest Maj. Wtr. Body
/unkn)
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Agent or Applicant Printed Name
Permit Officer's Printed Name
Signature ex Please read compliance statement on backo per i['* Slgnatur
Application Fee(s) Check# �� 15suing, ate • Expiration Date's

Hurricane Florence and TS Michael
Replacement/Repair Request Form
Date of Request:
Property Owner Name:
Address of Property: / 0 0 NIJW P8 L (,rC-GL /X c 4;w- cA
p A/c. .
Telephone Number: 6 3 Y-
Type of Work:
NOTE:
• The Emergency CAMA General Permit 2500 is for repairs and replacement of water -
dependent structures damaged because of Hurricane Florence and/or TS Michael. The
replacement, reconstruction and maintenance excavation activities shall conform to
current standards and rules. All work under the Emergency CAMA GP 2500 must be
made in the same footprint of the previous structure with no additions, expansions, or
enlargements.
• If any portion of a structure being replaced is within the 15' setback of the riparian line or
access area, signatures of the adjacent riparian property owner(s) must be obtained
acknowledging the notification and waiver of the setback on the forms provided by
DCM.
• Any maintenance excavation or dredging requires signatures of the adjacent riparian
property owner(s) on the notification forms provided by DCM.
Signature: ,,, '�q
RECEIVED
AUG 0 6 2019
DCM-MHD CITY

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