Williams, JoAnn

IYCAMA / ❑ DREDGE & FILL - 1 NO. 75207 A B C D
UMG,ENERAL PERMIT Previous permit#
1New ❑Modification El 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
1
Rules attached.
Applicant Name Mr' % AU) "o f! I Project Location: County L.✓
Address / V ' �r �y 1 "L 1V ( Street Address/ State Road/ Lot #(s) /G(
City �i'� �jj �r/. r�i State lyL ZIP
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Phone # E-Mail Subdivision
Authorized Agent
❑CW
Affected
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❑ PWS
ORW:
yes )/ no
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PNA yes'/ no
City —
Phone # O
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Closest Maj. Wtr. Body
ZIP
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River Basin
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Agent or Applicant Printed Name
Signatyre r"r Pleaseread compliance statement on back of permit"
Application Fee(s) Check #
Permit Officers Panted Name -/
Signatpre
Issuing Date / Expiration Date