Cauley, Jim

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®❑LAMA / ❑ DREDGE & FILL lF �___ . No. 75085 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
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
❑ Rules attached.
Applicant Narrte ' Jult Project Location: County _
Address )11� L Street Address/ State Road/ Lot #(s)
Citv',. .
Phone # (.--""b), - . —rA&Mail
Authorized Agent
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❑PTA
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A
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❑ HHF
ElIH
❑ PWS:
ORW:
yes / no
PNA
yes / no
ZIP
❑ ES ❑ PTS
❑ UBA ❑ WA
Subdivision
city ---
Phone # (_ )
Adj. Wtr. Body
Closest Mal. Wtn Body_
ZIP --
'River Basin
_(nat /man /unkn)
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Agent or Applicant Prirtecf Name
Signature `" Please read complian statement on back ofpermit
Application Fee(s) Check #
Permit Officer's Printed Name
Signature
'/ / / /

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