Crumpton, Elizabeth

®❑LAMA / ❑ DREDGE & FILL No. 75083 A B C D
GENERAL PERMIT ,) Previous permit#
9New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authodized 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.
1
Applicant Nam(
�roject Location: County
Address L__/ L.;I L, i " !) i �/;',/,9( Street Address/ State Road/ Lot #(s)
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Subdivision_
Authorized Agent
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City - _ZIP_
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❑PTA ES ❑PTS_
Phone# (_ ) River Basin_
Affected
AEC(s): ❑OEA ❑Ii
01H ❑USA ❑N/A
Adj. Wtr. Body (nat man/unkn)
❑ PWS:
Closest Maj. Wtr. Body-- - - - - -- -
ORW: yes / no PNA
yes / no
Type of Project/ Activity
Per
Fixet
Float
Finge
Groh
Build
Basir
Boat
Boat
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A building permit may be required by:
( Note Local Planning Jurisdiction)
Notes/ Special Conditions
e/ <7
Agent or Applicant Printed Name
Signature " Please read compliance statement on backof permit*'
Application Feels) Check#
❑ See note on back regarding River Basin rules.
PermitOfficer's Printed Nai
Signature
Issuing Date Expiration Dat

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
S
Name of Property Owner Requesting Permit: YJt/Gl (1�
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits. �j ��
necessary for the following proposed development: e `1 "• �" /it
P�5+1n 6i f: P, v Ac-c
a my property to ated at2 .7— �( "C�wy
in Cr County. A4 brr C- `4
1 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.
Pronertv Owner Information:
�' Title
�1 q
Date
This certification is valid through l-2il 3 ( lI

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