Nyborg, Phillip

®❑CAMA / n DREDGE & FILL NO. 73934
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GENERAL PERMIT Previouspermit# , C; D
❑New !-JModification ❑Complete Reissue C Partial Reissue Date previous permit issued�� l_
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 �''
EyJRules attached.
Applicant Name i 11 , k 1_1,/ l ">t Cf Project Location: County %,
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Address
City State- - -zip
Phone # (�) (. (' -.i E-Mail -__-
Authorized Agent I' 'II
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❑ PWS:
ORW: yes / no PNA yes / no
Street Address/ State Road/ Lot #(s)
City '��'(_ j ZIP
Phone # O River Basin i
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101011MIUME
Agent g^ Applicant Printed Name
Signature "Please read compliance statement on back of permit"
Check #
Permit Officer s'Printed 'Name
Signature
Issuing Date EI ation� Date

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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address: If M OA bow (\: U)\) O r .
Ct_ (11 G r�lL4 I l�L '2751­7
Phone Number: (q (a)
Email Address: j� h iV1 )2o �cq o{�MG�i Goy
I certify that I have authorized 0 O431iY CA H o V CD Pl 5 TJ� V C T i D INC.
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: () ® G I,-- &
1�o K/tJAL,uWAo>.i S i 1^,> C IoIJ
at my property located at 56 c I y (« N p k ky 0 (2 C- N T()Ly r\l L
in /i L t G o County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature ( II
Print or Type Name
Title
"1- G' 1 R
Date
This certification is valid through Z / 2161 2 U 2U