Shipley, Bob

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❑C ffl A /, El DREDGE & FILL �� j r'�`1 r—�' No. 73930 �r
-� A B l/ D
GENERAL PERMIT Previous permit# ll
❑New ❑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 �l'/
Address 1-II � I Street Address/ State Road/ Lot #(s)
City ��� r� ri �� State %%/ ZIP
Phone # 1. E-Mail
/
Authorized Agent j) i /// '&', ,
Affected CW ❑ EW ❑ PTA ❑ ES ❑ PTS
AEC(s): LJOEA ❑HHF ❑IH ❑UBA ❑N/A
❑ PWS:
ORW: yes / no PNA yes / no
Subdivision_
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City____j ZIP
Phone # O _ River Basin / ' ' f (l/l
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Agent or Applicant Printed Name
Signature •' Please read compliance statement onback ofpermit"
Fee(s) Check#
PermitOffcer's
d Name
Signature.
Issuing Date J Expiraton Date

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AGENT AUTHORIZATION FOR LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit; Co t x t A v
Mailing Address:. 3D�
Phone Number:.
Email Address; PLE`I1�-AZU-1 .�` �,t°�i,
I certify that I have. authorized' �h�. D R S
Agent I Contractor
to act on my behalf, for the purpose ofapplying for and obtaining all CAMA permits.
neces r the following proposed development:
at mY.property located at 3 (A)
in TS S kuW County.
I furthennore:certify that_! din authonzed. to grant, 'and do in fact grant'pennlsslon tQ
Division of Coastal Management staff; thg Local Permit Ofhcet and. their agents fo enter.
onthe aforementioned lands_ in • connection wJtb.evaluaBng infonnatioh related to thi:
Permitapplication.
Property owner Intormatttonn:
,snG� eLL_ FFy
S{k-t�4
Pdnt or Type Name
Tina
l Date
�r�l
This certification Is valid through j t-
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