Russell, Jack Jr.

t]CAMA / ❑ DREDGE & FILL
NO. 75067
A B' C D
GENERAL PERMIT
®
Previous permit#
�2NeW ❑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 aurhed.
Applicant Name
Project Location:
County
Address r
Street Address/ State
Road/ Lot #(s)_
_ -
_
City State; ZIP
_
Phone # O� E-Mil
Subdivision
Authorized Agent / i it ' n-
City
ZIP
❑CW ❑EW ❑PTA ❑PTS
Phone# ( )_
/ River Basin
,aES.
Affected ❑OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
AEC(s):
Adj. Wtr. Body
-
(nat an /unkn
❑ PWS:
i )
ORW: yes/ no PNA yes / no'-)
Closest Mal. Wtr.
Body
Type of Project/ Activity
Pier
Fixe
Float
Fing
Groff
Bulk
Basil
Boat
Boat
Beat
Oth.
Sher
SAV
Mor
Phot
Wait
(Scale: / )
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max distance offshore
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A building permit maybe required by: ! (/ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction) Notes/ Special Conditions
Agent or Applicant Printed Name
Signature "Please read compliance statement on back of permit"
Application Fee(s) Check #
Permit Officers Pants' Name /
Signatule
IssuifJ/ ng Date - Expiration Date
L

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:h
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
2,62-241-.37,40-
NoIruSseIIC' !�tnctiI.cL�rn
rltk'
Agent
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: Ise.pu i 5C'C4 VUA.1 1
e �D
at my property located at
d
in 00 i4ci'tt County.
I furthermore certify that I 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.
Property Owner Information:
Signature
j CkC RU5SC 11 fir.
Print or Type Name
� Ut) dam' td
Title
rl I I I 12u I
Date
This certification is valid through / i