72772D - Olsen

'"CAMA / -i DREDGE & FILL NO. 72772 A B C
GENERAL PERMIT Previous permit #
]New ❑Modification El 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
n
ElRrles attached.
Applicant Name �1 `OA "I � (�/V� Project Location: County ('64 70a
Address -1 M Street Address/ State Rpiid/ Lot )
Ciry -F CAT14 —StateNC., ZIP t'S 4419 qI Dg -1 `t,
Phone # 10)21 r -Mail Subdivision
Authorized Agent City -)U F ZIP
Affected ❑ CW OW )&TA ❑ ES ❑ PTS Phone # (----- f —" ,J River Basin /�/l�
❑ OEA ElHHF ElIH El USA ❑ N/A S")� ( at unkn a
AEC(s): Adj. Wtr. Body
❑ PWS:
-' Closest Maj. Wtr. Body �^
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Type of Project/ Activity
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A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
❑ See note on back regarding River Basin rules.
4�w
ent �rp lican Name Pe it icer's Printed Name
Y -�
Si ature ** Please read co ante statement on back MftlSi to
AO
Application Fee(s) Check# Issuing Date Expiration Date

F
me of Property Owner RevuestkV Permit: � 0 A �C `
#
Mang Address: 94
Phone Number: � � � � � ai � j . 1::.► ``� � `?
Email Address:
c+Q
to act on my behalf, for the purpose of applying for and obtaining all CAMA pew
necessary for the fallowing proposed development:
)b
at my property looted at rS r)
in 4-)C f\diC_ C County.
I furthermore certify that I am aufhorized 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 Informat,iala:
Signature
2��?-Orti 1 ?,, t C, C--�` sj e n
AW or Type Name
Tide
Die
This certiFmbon is valid through -1 - l

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Date Received
Date De slhW
Clack From IName
Name o/ Pormlt Holder
Vendor
Check Number
Check
amount
Pormlt Numbwlcommente
Recel t or Refurrd/R.O.-ted
Column!
Column!
Column3
Column!
Co1umn5
Co/um.
Column?
Columns
Column9
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