Veltman, T. J.

ICAMA / Ll DREDGE & FILL NO, 75718 -. A B C D
GENERAL PERMIT Previous permit#
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
r
As authorized by the State of North Carolina, Department of Environmental Quality
and tie Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
( ! [-I Rules attached.
Applicant
Name i�� /1 1 rL(..�� Project Location: County
—
Address _
' l" / I J lj ^ Street Address/ State Road/ Lot #(s)
City State UZIP1''%7 _
j 7 y Subdivision
Phone #,(��� /.��"'_ E-Mail ---
Authorized Agent City 1 U r - I : ( �;^ ZIP
Affected Dt�w ENEW A ❑ES ❑PTS Phone# (�) _ River Psin'__
AEC(s): A ❑HHF 1 ❑UBA ❑N/A
Adj. Wtr. Body nat .ma
ElPw � �
ORW: yes / a PNA es / no Closest Maj. Wtr. Body '
Type of Project/ Activity -.-_.-_.._____..___._...._.__.__. _.. .--...._.......
(Scale _.
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pler(s)
Groin length
number
Bulkhead/ Ripmp length_
avg distance offshore
max distance offshon
Basin, channel %
cubic
Beach
Other
Shoreline Length
SAM not sure yes no -- -
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no
A building permit may be required by:
( Note Local Planning Jurisdiction)
Notes/ Special Conditions
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Agent or Applicant Printed Name
Signature **' Please read compliance statement on back of permit"
1 ❑ See note on back regarding River Basin rules.
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PermitOfffcers Printed Name ( /`
Signatur
Issu ng Date T �� Expir U Da e
Application Fee(s) Check#

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: %. J.. ble,11,7az
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
Za �6_ o
Agent
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: e�Ioc e d-CK w FAI -1_
at my property located at
in Cz?r •krC7 County.
rc- F- o�cC
W,
1 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:
Signature
Print or Type Name
Title
cey /
Date to
This certification is valid through cam"' _I %o I 12off
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