Cheek, Donna

®ElCAMA / ❑ DREDGE & FILL \ NO. 74434 A B C D
GENERAL PERMIT Previous permit#
❑' ew ❑Modification ❑Complete Reissue ❑Partial Reissue Date revious permit issued
a
As authorized by the State of North Carolina, Department of Environmen& Quality ( i
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC y'
Rules attached.
` \{ Project Location: County 1
Applicant Name (\� —�
Address
City _ State ZIP
Phone # �)_ 11�-Mail
Authorized Agents._.. -
Affected 41Cw L EW C PTA ❑ ES ❑ PTS '
AEC(s): nOEA LHHF IIH ❑UBA ❑N/A
❑ PWS
ORW: yes / no PIMA yes / no
Street Address/ State Road/ Lot #(s) \\
Subdivision_
City ZIP
Phone # ( _.) ,River Basin
Adj. Wtr. Body__, (nat /man /unkn)
Closest Maj. Wtr. Body _
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Agent or Applicant Printed Name
Signature *'*' Please read compliance statement on back of permit
Application Feels) Check #
Permit Officers Printed Nam-e�
Signature
Issuing Date l ( Expiration Ae

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: ?7olW O a-leet
Mailing Address. 2�2,7' Si/ol( W/I/E
moR.FN«U cil Nc 26'Sf 7
-3hone Number:
Email Address: Wc,.4rrl- Z.SZ (0 c;rrr-x <v�i
1 certify that I have authorized f 6e4, Ac_�4j_
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
/L 10A,f2 /l%K /n/ SAM( roh7' f7eijt/1'
at my property located at ;7�?Z�7 S��n/IE Pllr✓f ��/1/u'nJ c;7:'
,
in CAQ7F4E7 County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
�rvision 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�G✓NF�
Title
� ,• �S , Zoi i
Date
This certification is valid through 17 / Z S I Zw j RECEIVED
APR 2 5 2019
DCM-MHD CITY