Peacock, Greg

�EICAMA / I—' DREDGE & FILL r No. 73920 A B C D
C !NERAL 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 j i I I I ,
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC ,/ III {
Rules attached.
Applicant Name_; Project Location: County
Address - Street Address/ State Road/ Lot #(s)
City State ZIP 7.
Phone #
E-Mail
Authorized Agent •t . (r
Affected C)CW ❑EW L�\PTA ES ❑PTS
AEC(s): El OEA ❑ HHF ❑ IH BA ❑ N/A
❑ PWS:
ORW: yes / no PNA yes /;'no
Subdivision
City - ZIP
Phone # i��)tD� ] ) River Basin _
i
Adj. Wtr. Body �' f)` 4 i (nat /man /unkn)
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Closest Maj. Wtr. Body
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Agent or Applicant Printed Name
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Signature '** Please read compliance statement on back of permit"
Application Fee(s) I Check#
Permit0(ficer's Print d Name
Signature _
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Oaacn PQGLoC
Mailing Address: g104 ►jor'MOLA 12c1
�i.W l3er Y1 � i.� t, e`(i45I,t1
Phone Number:,
Email Address:
I certify that I have authorized T ' t,,J • Mar, ,a,� Yw[,E; m, L G
Agent! Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: h/Qk 7 Qq K) a ( ;QT.
at my property located at ?jam$ F\nU.., Slr �p� 2 „ d
in C cku QA- 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
--- y
l b ' P G- C
Print 6r Type Name
i_f�l_ 1 �_
Date
This certification is valid through J_�!_
RECEIVED
MAR 2 5 2019
DCM-MHD CITY

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■ CamLiYi�
plate Items 1, 2, and 3.
■ Pdnt your name
A.'Signatwe '
and address 0n the reverse
so that we cart return the card to you,
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■ Attach this card to the back of the mallpiece,
or on the front if s ?aDo Permits.
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below:
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7018 0360 0001 5712 6411 MI 06 Mureomrimegan
PS Form 3311, JUIy 2015 PSN 7530.02.000�05s 0 gesMetetl Delivery Restrictetl Delrvm!
.. Domestic Return Receipt
■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mallpiece
Or on the front if — --- ----
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PS Form 3811. JUIy 2015 PSN 7530-02-000-908? __..0 a aaw —...
Domestic Return Receipt

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