Denson, Dalton

®❑CAMA / ❑ DREDGE & FILL l i (I )y' `y 1��� I�O 75938 A 8 ;C D
GENERAL 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 J J - Project Location: County
Address / _ Street Address/ State Road/ Lot #(s)
City i Atate - ZIP ? __
Phone # (},_
Authorized Agent
Affected CW
AEC(s): El OEA
❑ PWS
ORW: yes / no
it Subdivision-
City— — �, ZIP /
L]EW El PTA �ES ❑PTS / Phone# River Basin
J HHF O IH /❑ UBA ❑ N/A Adj. Wtr. Body (nat /man /unkn
Closest Mal. Wtr. Body F
PNA yes / no
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Signature f '*"* Please read compliance statement on back of permit*�
ii
Permit Officer's Printed Name
y.
Check# Issuing DaiW / ' y ! / Expiration

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: �Dp I 1f n5on1
Mailing Address: w E: N
RECEIVED
PhNOV one um�e19 lQ 232. ;15
DCM-MHD CITY
Email Address:
I certify that I have authorized nl �)o'-BLc.KZ-1 Y[�r �l►�lc, 1 L• ,
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: -7-y) 4cI= —i IQIQL Z-))
L drrkCaN:;�
at my property located at 1
-30
in C County.
C.
1 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
&222'',
Print or Type Name
Title
f'� ! 4Z /Iq
Date
This certification is valid through /

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