Gibson, Martyn

�GFCA IAA / ❑ DREDGE & FILL >/ % -- No. 73981 A B C D
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—WERAL PERMIT Previous permit#
`° 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 Co.Wission in an area Qf env'r onme taI concern pursuant to 15A NCAC lle
��� /✓�� � / ❑Rules attached.
Applicant Name ri Jf<` Project Location: County ( r y I
Address Street Address/ State Road/ Lot #(s)
City ( / ,: '. State ��� ZIP 'cy3i'� / ( _rI by
Phone # O
E-Mail
Subdivision
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Authorized Agent
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City </ '
ZIP J!�
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EJP A ❑ ES ❑ PTS
Phone # ( )
River Basin
Affected OEA ElHHF
AEC(s):
❑ IH ❑ UBA ❑ N/A
Adj. Wtr. Body � '
" (Ij �" nat man Junkn
❑ PWS:
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ORW: PNA
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Closest Maj. Wt.. Body
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/' yes,"/' no
yes
Type of Project/ Activity
(Scale: )
Pia
Fize
Float
Fing
Groi
Bulk
Basi
Boat
Boat
Beac
Oth
Short
SAV:
Mor,
Phot
Waiv,
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A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
I l
Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit**
Application Fee(s) Check #
❑ See note on back regarding River Basin rules.
PermitOffic€ P i ted Name
Signatur %
Issuing Date Expiration Date

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date J- 16 ~ I I
Name of Property Owner Applying for Permit:
Mailing Address:
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All 2�eE3/Z
I certify that I have authorized (agent) I �'�^ a S Cxo act on my
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behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at) % � _ 421 it i Q-
This certification is valid thru (date) 4 2 120 2-,0
Property Owner Signature
7/,;i
Date
J1110 aHW-WOQ
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