Hoyt, Sally A.

NCAMA / ❑ DREDGE & FILL
No. 74990
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GENERAL PERMIT
A B C D
Previous permit#
New ❑Modification ❑Complete Reissue 04brdial Reissue
Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Com ission in an area of environmental concern pursuant to 15A NCAC
!
�R°lesatta<n ed.
Applicant Name %1_�
I 1,/ I 1 ' �I i f �
Project Location:
County �
t
Address
1( d 1,Street
Address/ State Road/ Lot #(s)
(.City State 1 ZIP
Phone # (�) _)� (� �i" (._ ail
Subdivision
Authorized Agent i 1 l j i r 1 l �' _
City
1 ZIP
/
N,CW OEW �� TA ❑ES ❑PTS
Affected
Phone# ( )
i ( River Basin
/
AECi ❑ OFA ❑ HHF IH ❑ 1 ❑ N/A
Adj. Wtr. Body
Y (nat /man /unkn
❑ PWS
ORW: yes / no PNA yes / no
Closest Maj. Wtr.
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Agent or Applicant Printed Name
Signature •'Please read compliance statement on back of permit**
Application Fee(s) Check#
PermitOfOcer's Printed Name
Signature l _
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR LAMA PERMIT. APPLICATION
Name of Property Owner Requesting Permit: // 4-4
Mailing Address: /O % �GLEnc%yie� C�27
Alol,lfv„eT. /V/' '96S4;'0
Phone Number:
Email Address:
I certify that I have authorized
(o7sa� 7d3- oo/ 9
o 4 Wr*ail. Cb/3'/
Agtea ver Rt 55 ,3u,
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at ma�y ay located at /D 7 .'SOGt, c/
in 1 4�4L4 County.
I "M
)OIL-7 ,/1/C
1 furthermore certify that l 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:
- a
Signature
Print or Type N me
Title
l to c RECEIVED
Date
JUN 14 2019
This certification is valid through / / DCM-MHD CITY

Hurricane Florence and TS Michael
Replacement/Repair Request Form
Date of Request: 6 lP - /a - 6? O/
Property Owner Name:
Address of Property:
Telephone Number:
Type of Work:
NOTE:
Lg2.
c9S-a 7a3 - a o i g
The Emergency CAMA General Permit 2500 is for repairs and replacement of water -
dependent structures damaged because of Hurricane Florence and/or TS Michael. The
replacement, reconstruction and maintenance excavation activities shall conform to
current standards and rules. All work under the Emergency CAMA GP 2500 must be
made in the same footprint of the previous structure with no additions, expansions, or
enlargements.
If any portion of a structure being replaced is within the 15' setback of the riparian line or
access area, signatures of the adjacent riparian property owner(s) must be obtained
acknowledging the notification and waiver of the setback on the forms provided by
DCM.
• Any maintenance excavation or dredging requires signatures of the adjacent riparian
property owner(s) on the notification forms provided by DCM.
Signature:
N
RECEIVED
JUN 14 2019
DCM-MHD CITY

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