Smith, William B.

n CAMA / ❑ DREDGE & FILL No. 73962 A B C D
GENERAL PERMIT Previous permit#
ENew ❑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 I SA NCAC
-� r l Rules attached.
Applicant Name_ Project Location: County
Address_ ` r 1 V' - i Street Address/ State Road/ Lot #(s)
City i I State it,
ZIP
Phone # (/%. ) E-Mail Subdivision
Authorized Agent
Cw
Affected
AEC(s):
� OEA
❑ PWSWS
ORW:
yes /;no
City.
P,IV
,NJ EW ❑ PTA ❑ ES ❑ PTS Phone # ( ) River Basin / I
❑ HHF f- IH ❑ UBA ❑ WA
Adj. Wtr. Body ��! F �'( [(nat /man /unkn)
PNA yes / no Closest Maj. Wtr. Body '</ /�
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Agent or Applicant Printed Norge
Signature -`'Please read compliance statement on back of permit••
Application Feels) Check #
Permit Officer's Printed Name
Signature
Issuing ate Expiration Date

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U.S. Postal Service'"
CERTIFIED MAIL® RECEIPT
Domestic Mail Only