Jackson, Mark

❑ (;� A / ❑DREDGE & FILL NO. 75787
A B D
PERMIT Previous permit #
L7New . ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resourcgts Commispion in an area of environmental concern pursuant to I SA NCAC 7` (_
/'./f ✓1 /� ❑/'lesattached.
Applicant Name �' J y j f Project Location: County (✓ ^J `
Address y' t / J A ���t / Street Address/ State Road/ l,ot #(s)
City j �.,,.y; y StateNt'z,P d� �� ! l.�i
Phone # (���i)' � t�j'`�,1 /4-Mail Subdivision
Authorized Agent City
Affected ECW CEP/ oPTA ❑ES ❑PTs Phone# ( ) River Basin C
C
OOEA ❑HHF ❑IH ❑UBA ❑N/A
AEC(s): Adj. Wtr. Body X <" " "man unkn
❑ PWS: e
' / Closest Maj. Wtr. Body ]....t!57 "
ORW: yes /tno , PNA yes /yho j -
Type of Project/Activity 1. a� �` cyt (- (�/..-�,. /,,.— ! /I
(Scale: %� )
Pier (dock) length _
rI
Fixed Platforni
Floating Platforms) �_ _
Groin length
avg distance <
max distance
Basin, channel
cubic
Boat ramp
Boathouse/
Beach
Other
Shoreline Length f
'
'--
SAV: not sure yes
-..._ .._ -'
Moratorium: n/a - yes o
-- '
Photos: a yes o ,
1
_
/
Waiver Attached: yes �no)
..
A building permit may be required by:
1 Vt % v l
See note on back regarding River Basin rules.
( Note Local Planning jurisdiction)
,';� .� i
r
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/�( -//
Notes/ Special Conditions
Agent or Applicant Pi rated Name
Permit Officer'
hinted Name
Signature ** Please read compliance statement on back of permit*s` Signature ,/,
Application Feels) Check # Issuing Dade Expira ion Date

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