Bass, Anderson

ICAMA / I 1 DREDGE & FILt `_ ( I 1V0. 74478 A B /C D
GENERAL PERMIT Previous permit#
'Nevy ❑Modification []Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality % J
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC S
❑Rules attached_
Applicant Name Project Location: County
Address
City State IZIP
Phone # (
:101
Authorized Agent
yW
Affected
�W PTA
0 OEA
HHIHA
❑ PWS:
ORW: i yes /.no
PNA yes /
Type of Project/ Activity
Pier
Fixe
Floa
Fing
Groi
Bulk
Bash
Boat
Boat
Beat
Oth
Shor
SAV:
Mor
Photo
Waiv
Street Address/ State Road/ Lot #(s)
Subdivision ,
ZIP;
❑ES ❑PTS Phone # //,,' {Aiver Basin
❑ UBA ❑ N/A } '
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A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant
Signature Please read compliance statement on backofpermit** ,)
Ii�''G_/
Application Fee(s) Check#
❑ See note on back regarding River Basin rules.
PermitOffcer's Printed Name
i
Signatu\e `
/, � Ile
Issuing ZZI Expiration Date

Hurricane Florence and TS Michael
Replacement/Repair Request Form
Date of Request: t' a
Property Owner Name:
Address of Property:
Telephone Number:
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:
,CEIVED
�AY 0 9 2019
BW.MVAD CITY

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