Sanborn, Robert & Lori Beth

®!CAMA / ❑ DREDGE & FILL / 1 No. ` 75051 A B C D
GENERAL PERMIT Previous permit#
New ❑Modification ❑Complete Reissue ''._.Pa tial Reissue Date prev[ous permit issued
As authorized by the State of North Carolina, Department of'p-wronmental Quality /
and t4 Coastal Resources Commission n an area of envirc i ental concern pursuant to I SA NCAC '
SS,, E] Rules attached.
Applicant Name �.x �t` i) i �c. j Project Location: County- _
Addre l I < t Street Address/ State Road/ Lot #(s)
City !� ((�l.- t�
Phone # / Mil Subdivision
Authorized Agent CityZIP
Affected ElCW PTA OPTS Phone# ( ) River Basin
AEC(s): oOEA ❑HHF ❑IH ueA El Adj. Wtr. Body _ nat man /unl(n)
ORW: yes / no PNA yes /ono Closest Maj. Wtr. Body — -
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Agent or Applicant Printed Name
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Signature **PleasergadcWnpliance statement on backof permit**
Application Fee(s) Check #
Permit Officer's Printed
/ Signature
Issuing Date
v
Expiration Date

Hurricane Florence and TS Michael
Replacement./Repair Request Form
Date of Request: 5
Property Owner Name: �6 Q V�
Address of Property:
Telephone Number:
Type of Work:
NOTE:
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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.
�t , �C
• 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:
RECEIVED
JUL 15 Z0
DCM-MV'D CITY

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