Fomelies, Willet

®❑CAMA / ❑ DREDGE & FILL I �;, , No. 74429 A B L D
ENERAL PERMIT Previous permit#
lo� ew ❑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 )
❑ 7ules attached.
�, I ^�; Pro n r
Applicant Name Project Location: County
Address ✓T � L, Street Ad, ess/ State oad/ Lot #(s)
1 t_
City— .�r�; ��"/' / Stated/( ZIP
Phone # (:- "(') I I' r E-M it Subdivision
Authorized Agent��C'
Affected C19 ❑-EW ❑ pTA O ES ❑ PTS
AEC(s): OEA ❑ HHF ❑ IH ❑ UBA ❑ WA
❑ PWS:
ORW: yes /ro PNA yj4s / ro
City ZIP�//II
Phone # O River Basin
Adj. Wtr. Body C /��'''' - n__at man unkn
Closest Maj. Wtr. Body
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Ajem10Appllca5 rioted ame " Permit Ofjrc'r's Printed Name ;
Signature -' Phase read compli nce statement on back of permit''"' Sign a ur
Application Fee(s) Check# Iss i gDat /Expiration l5ate

a
N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date // - Z --4K
Name of Property Owner Applying for Permit:
Mailing Address:
Z
I certify that I have authorized (agent) G�fii .S ��� Wi��to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at) fl LC_Sfi �a�^'-)4
r
N
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2k5 3
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This certification is valid thru (date) / / - z - Z' 0 / /
Owner Signature
Date
RECEIVED
MAR 13 2019
DCM-MHD CITY