Carver, Fletecher Hall III

_10AMA/ El DREDGE & FILL l "r r No. 74999
�. A B (C D
GENERAL PERMIT Previous permit#
New' ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality L
and the Coastal Resources Commissio in an area of environmental concern, pursuant to I SA NCAC /
/ � ules attached.
Applicant Name_ /r' �! f r // "! / Project Location: County ( r v �r% `�
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Address - C- Li 1 J r �_ 7"" L ,� Street Address/ State Road/ Lot #(s)
City State ZIP --�-i�
Phone # ( (_� f /) ' hJ E-Mail Authorized Agent )
Affected ElCW p6W ❑PfA DES ❑PTS
AEC(s): ❑OEA ❑HHF ❑IH ❑USA ❑N/A
❑ PWS:
ORW: yes / no PNA yes / no
Subdivision
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City-
Phone # O River Basin
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Agent cr Applicant Printed Name ,.
PermitOfficer's Printed Name -
s. Please read compliance statement on back of permit"
Application Feels) Check #
Signature /
Issuing Expil'ation Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 1'�r �Ht�z H�« Cthzv�2 iy
Mailing Address: ' 60:4 tUH1-,c- ChAPF� u/f+
t`?iA-LE'iGN Ale 2�1015-l67�
Phone Number: 5'r9-�7J 6<v8 y!9_�lF�' 287�
Email Address:��2SF��;c
I certify that I have authorized
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: IA"' 4pc-" rY'�'L
Kvr� j go ue ';)o,v,) P"Al ?�-A/xfjcn E" '�Lt�2a��,r - F/'=� a,c
at my property located at o9-01arz Qc o 7��z v� Hinz. gt>> l scc N� 29SG
in �er2�� County.
1 furthermore certify that 1 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:
C' A:�," -��—
Signature
f�r�-iC/rz/i l%`Au GrflRd� l�
Print or Type
Title
Date
This certification is valid through I

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