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I�,CAMA / ❑ DREDGE & FILL - ' ; ( No. 75065 A B .'C D
GENERAL PERMIT Previous permit#
C New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality _
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
j I J1 Rules attached.
Applicant
Ci'A �� � '-t �/ State ZIP
Phone # ( ) .� ? / P-M-Mail
Authorized Agent
Affected OcW ❑EW 6-PTA El ES ❑PTS
): ❑OEA ❑HHF ❑IH ❑UBA ❑N/A
AEC(
❑ PWS:
ORW: yes / no PNA yes /, no'
Project Location: County
Street Address/ State Road/ Lot #(s);r/7�;
r
City ZIP
Phone # O ( River Basin
Adj. Wtr. Body (nat/man /unkn)
Closest Maj. Wtr. Body
I
e of Project/ Activity j,
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Agent or tMicant Printed Name
Signat r **Please read compliancestatement on back of permit''
I1j! i
Application Fee(s) Check #
PermitOfficers Printed Name --
Signature
Issuing Date- Expiration Date