Birk, Carl Jr.

❑CAMA / ❑ DREDGE & FILL / I' " .I r ( NO. 73980 '
-+ A B (C D
GENERA. PERMIT Previous permit#
[?�e`W ❑ModificaRion ❑Complete Reissue .. ❑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 15A NCAC
Jj' i' ❑ Rules attached.
Applicant Name Project Location: County
Address
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Street Address/ State Road/ Lot #(s)
City
State !,/
ZIP 1 7
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Phone # O -
E-Mail
Subdivision_
Authorized Agent
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City ZIP
El QW
DEW
❑ PTA DES
❑ PTS
Phone # ( ) River Basin
Affected
_
AEC(s): DOEA
ElHHF
El 1H ❑ UBA
❑ N/A
Adj. Wtr. Body " (' ' .� (hat /man /unkn)
ElPWS:
i /
Closest Maj. Wtc Body t') -
ORW: yes' / no
PNA
yes / no
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Agent or Applicant Printed Name
Signature r* Please read compliance statement on backof permit"
Application Fee(s) Check #
PermitOfficer's Printed Name
i
Signature
lssjink Date Ecpiration Date

Date of Request:
Property Owner Name:
Address of Property:
Telephone Number:
Type of Work:
Hurricane Florence and TS Michael
Replacement/Repair Request Form
�1
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:
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