Edwards, Vance

®CAMA / ❑ DREDGE & FILL No. 75916 A B C D
GENERAL PERMIT Previous permit#
❑New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality r ..
and the Coastal Resources Commission in an area of environrnental concern pursuant to 1 SA NCAC f.,r
`) ❑ Rules attached.
Applicant Name V ^ /' '( l V Project Location: County
Address ? r i Street Address/ State Road/ Lot #(s)
City State I f ZIP -
Phone # ( ! �) L E-Mail Subdivision ( /
Authorized Agent (' t l l (' 'I/ i " /' , Cityl / r n'! ! G t� { C ' ZIP f '
Affected ❑CW ❑EW El PTA _kES ❑PTS Phone# ( ) River Basin
AEC(s): UOEA ❑HHF ❑IH ❑UBA ❑N/A Adj. Wtr. Body (nat/man /unkn
❑ PWS:
ORW: yes / no PNA yes / rio Closest Mal. Wtr. Body.
0 0 OEM MEN 111111 SEE Emile'
reline tos: yes no
iver Attached: yes n2 -
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Agent or pplicant Prnted Name PermitOffcer's Printed Name
Sign pure **Please read compliance statement on back of permit" Signatur0' .
i t/y / II
Application Fee(s) Check # Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT _APPLICATION
Name of Property Owner Requesting Permit: Y L'ir z z �,
Mailing Address: t, S ( c ,. e, `
-757(i
Phone Number:
Email Address: _ _ 1lll� �;/ 11 tjAf.SCC,
I certify that I have authorized M i r r,> > z ,
Agent i Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following propot;.d development:
Dam ray Iy Y' r l c �w fi DO + t ,.J
at my property located at 'Z2 Arzh0re•V i +a t= C�
in Cg-f 4- , ll County.
I furthermore certify that 1 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
Signature
Print or Type Name
d t,.r` h,-Ce-
Date
This certification is valid through t
RECEIVED
OU 2 9 Z019
DCM-MHD CITY