Joyce, Johnna

®C' GAMA / —1 DREDGE & FILL No. 74938 A B C D
GENERAL PERMIT Previous permit#
LINeW ❑Modification ❑Complete Reissue El 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 Name Project Location: County
Address .)
City / '7 1, State ZIP (' }
Phone # (�� �) � -1 �� � E-Mail
Authorized Agent
Affected El CAN QEW OOTA El ES ❑PTS
❑OEA ❑HHF ❑IH ❑UBA ❑N/A
AEC(s):
❑ PWS:
ORW: yes / no PNA yes / no
Street Address/ State Road/ Lot #(s)
—�
Subdivision
City ( � /., ; , (",' i 'v ZIP
Phone # () ( River Basin
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Agent or Applicant Printed Name 1
Signature a'Please read,compliancestatement onbackofpermit"
Application Fee(s) Check #
PermitOfFlcer's Printed Name
Signature /
Issuin�. xpirat;o Date

Date of Request:
Property Owner Name:
Address of Property:
Telephone Number:
Type of Work:
Hurricane Florence and TS Michael
Replacement/Repair Request Form
5 - 8-/ 9
/026 5hor-ellwe- hk GIouCe5i-eR iJC'
aka- Zap &a:2,
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:
V�vCEIVED
�Ay Oa2019
®CM,MHD c�SY

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