Grady, Randolph

�Y&MA / ❑ DREDGE & FILL No. 75069 A B C D
�GENERAL PERMIT Previous permit# �
ew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorizeB by the State of North Carolina, Department of Environmental Quality
and the Coastal ResourcZ Commi7io i i�area of environmental c cern pursuant to 15A NCAC / rV
/j f ❑Rule attached.
Applicant Name'y G.^ .y �9 .t e Project Location: County { Cr e'
Address " ^ v ic, J 7f / Street Address/ State Road/ Lot #(s)
City jj, / Y.,,/ A^ f State /"KZIP / 1 i 1 � .. rt'6
Phone#(E-Mail Subdivision
Authorized Agent ` II ty
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❑ PWS: l
ORW: yes / no PNA yes / nj� j
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A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
v� Ri 0� J�
Agentya plica,7t PrintedrNa" f -
SignatuYe�** Please read compliance statement on back of permit"
Appli gQrt e(s) Check#
❑ See note on back regarding River Basin rules.
Permit Officer's Printed N e
Signature �,_�) T 7(,/

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: / Awyo%4i P% 'SW
I
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
'/�39 i3Ay✓ie��/j
a-5'2- 5)5--2�?iz
4114
/n,4 6,1 Tdh 't" )SvOoK
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at y3 q %jam I/ v, r-� /�v. ✓°� �� � ^ d �`
,
in Cam fe �Vl- County.
I 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:
Signature 61
�C v6%� dW71 v �l /OCJi
Print or Type Name
Title
Date
This certification is valid through
RECENED
pCM.MHD CITY