Throckmorton, Hodges

/ ❑CAMA / ❑ DREDGE & FILL � �'�` 1 ( NO. 75017 A B C D
GENERAL PERMIT Previous permit#
New ❑Modification [:]Complete Reissua ❑Pai t,al Reissue Date previous permit issued
As auth�ized by the State of North Carolina, Department of EwOrohr a atal Quality
and the Coastal Resouyces Co mission in an area of environmental concern pursuant to I SA NCAC
❑ Rules attached.
Applicant Name / / / / )j + / )roject Location: County
Address __! ' ! , :.i % - (mil i' .f' Street Address/ State Road/ Lot #(s)
ZIP
Phone # /("����� �- (
Authorized Agent
Affected El CW - ❑ EW TA IDES ❑ PTS
AEC(s): OEA ❑ HHF ❑ H - ❑ UBA ❑ WA
❑ PWS:
ORW: yes / no PIMA yes / no
Type of Project/ Activity
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Fixe
Float
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Groff
Bulkl
Basir
Boat
Boat
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Sher
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Subdivision_
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A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
❑ See note on back regarding River Basin rules.
Agent or Applicant Printed Name -�' Y` Permit Officer's Printed Name
Signature "Pleaser Please statement on back of permit" Signat re
(77)
Application Fee(s) Check# Issuing Date r Expiration Dafe

Hurricane Florence and TS Michael
Replacement/Repair Request Form
Date of Request: I 2
Property Owner Name: 40,-)ASS -TA ✓v6 l Me9 46VI
Address of Property:
Telephone Number:
Type of Work:
NOTE:
Z `74 i C- D d L4 Nf LZ-�
re s; de,+ -Al -per
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.
Signa
FA
RECEIVED
JUN 21 2019
DCM-MHD CITY

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