74331D - Cook

AMA / XDREDGE & FILL No. 74331 A B CO
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RNERAL PERMIT Previous permit #
ew ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality I
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC 07 H . i i OU
❑ Rules attached.
Applicant Name RtA.f/�s (� IO'R 1O K
Address�f I1 / Pl1Et1) Nfoo DS �V E
City UOe.DSgop.o StateAtC ZIP2r7530
Phone # ( ) 314 - 743E E-Mail ZJA
Authorized Agent rc' PL LOILA/
Project Location: County 9Rust/5 w t e,S
Street Address/ State Road/ Lot #(s) 114
,IV_r a.F 1SN ,/ 191V�
Subdivision AIIA
City Hot_-OF—/V &�cN ZIP ;ZS4 Z
Affected ElCW ElEW El PTA VES WPTS 7 Phone # ( 1 o) 55+0 - bdj1 ORiver Basin 1�,,cLA�A
AEC(s): ❑ O� ❑ HHF [IIH ❑ URA El N/A Adj. Wtr. Body CAWA,�._ (nat /m� n)
❑ PWS: ilA 1 Ind W r.met Mei Wt.,
J
Agent or Applicant P nted N' e
Signs ure Please read compliance statement on back of permit*
¢D D * 3576
Application Fee(s) Check #
Permit Officer's Printed Name
Signature
5 12A 1 9 9 Z9 A9
Issuing Date Expiration Date

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Date Received
Date De osired Check From Name
Name of Perm/t Holder
Vendor
Check Number
Check
amunt
Permit NumberlComments
Receipt or Refund/Reallocated
Column?
Column) Column3
Column)
Column5
Column6
Column?
Co1umn9
Co1umn9
615f2019
Holden D ck and BWkheads
Rus Cook
-k
3576
S 40000
GP#74331D
TMc rct 0486

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