Chadwick, Jeff

�7"G4WIA ,, ❑DREDGE &FILL
GENERAL PERMIT
Y ew ❑Modification ❑Complete Reissue ❑Partial Reissue
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
No. 75223 A B D
Previous permit #
Date previous permit issued
15A NCAC / // <�.� ",
C` ❑Rules attached.
Applicant Name '> f` ' { rn Project Location: County
Address --- Street Address/ State Road/ Lot #(s)
City � •, ,i1'} f State': ZIP jLJJ t�
Phone # (if) E-Mail Subdivision_
Authorized Agent " /c:"/"'t City
QCW new nPTA DES ❑PTS Phone#/( ) iver Basin
Affected 0 AEC(s)a OFA ElHHF �� IH n UBA ❑ N/A Adj. Wtr. Body `r (nat main unkn
❑ PWS:
ORW: .yes,/'no PNA yes / no.
Closest Maj. Wtr. Body
Type of Project/ Activity
Pier!
Fixet
Float
Fingt
Groii
Bulkl
Basir
Boat
Boat'
Beac
OthE
Shor
SAV,
Mor,
Phot
Waiv
(Scale i /(
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Bulldozing_
i
fline Length
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no
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yes
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torlum: rVa yes no
A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name '
c.-C...
Signature '" Please read compliance statement on back of permit"
Application Fee(s) Che #
i
❑ See note on back regarding River Basin rules.
1
Permit Officers Printed Na((pp��e
1__.
Signature ' !; /
Issuing ate Expiation Date

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit: i- f (�4 '4-4w: c /<
Mailing address:
U
Telephone Number: A V F- `j 10 -- ,? %W
I certify that I have authorized As L A-L,�, re, u o-e (agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of 1 •e. 4a i r c/oC' /c,
b Ad" nor "71 r
at my property located at f ai''�<< �c� c� C-
I kN) 1°
This certification is valid through �� �/ (date).
(Property Owner Information)
Print or Type Name
G Lt-7 tj er
Title, co. owner or trustee for property
( -
Date
;�4n- a 10- V 62
Telephone Number
Te-4 CpfPc1k0Me-.org
Email Address
RECEIVED
AUG 0 6 2019
DCM-MHD CITY

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