NC Marine Fisheries

DREDGE & FILL r` J;. ,i / c-, No. 74460 A B C ; D
G._ AAL PERMIT Previous permit#
❑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
❑ Rules attached.
Applicant Name_ ' ' ' T' ' '% . - ? Project Location: County
Addreec (; I ') V (A (,I i i I � J Street Address/ State Road/ L t #(s) /
Phone #
Authorized Agent
El cW
Affected
El OEA
AEC(s): C PWSWS
State/✓( ZIP,74
U 1 -Mail
n, I ) i
❑EW L1 PTA FLIES ❑PTS
❑HHF LIH ❑USA..IN/A
ORW: yes / no PNA yes / no
Subdivision
City ZIP � 'f�
Phone # O (River Basin
Adj. Wtr. Body` J , t._ 1(/._" Inat%n /unkn)
Closest Mal. Wtr.
Body -
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Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of
Fee(s) Check#