68566D - Angel

XCAMA _ .;EDGE & FILL
GENERAL PERMIT
L7lew Modification ❑Complete Reissue El Partial Reissue
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Previous permit #
Date previous permit issued
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As authorized by the State of North Carolina, Department of Environment and Natural Resources '� '
and the Coastal Resources Commission in an area of a vironmental concern pursuant to I SA NCAC ©, '
❑ Rules attached.
Applicant Name Project Location: County AM S',Sn
Address 5 I, ��T Street Address/ State Road/ Lot (s)
City (� 'V �, t State ZIP r
Phone # (i� — ��Do E-Mail LL Subdivision
Authorized Agent �7 �� t Un S (Vy City Q0' S�� �k ZIP
Affected ElCW )(EW )I PTA ❑ ES ElPTS Phone # (�I 0) D River Basin
AEC(s): ❑ OEA [IHHF /❑ IH ❑ URA ❑ N/A Adj. Wtr. Body C �4 0 L (nat / s /unkn)
❑ PWS: /A� i
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Agent or Applicant Priname Permit!
Signature Please read compliance statement on back of permit ** Signatu
Application Fee(s) .a. Check # Issuing
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Printed Narde
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127 Cardinal Drive Ext., Wilmington. NC 28405
Phone: 910-79&7215 \ FAX: [phone] Internet: www.nccoastaimanagement.net
An Equal Opportunity \ Afrumative Action Employer NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory
Governor
Braxton C. Dai John E. Skvarla, III
Director Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FORM
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory
Governor
Date:
Nre of PTperty Owner Applying for Permit:
Owner's Mailing Address:
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Phone Number (1'14-1 tool —LLI gib
Braxton C. Dai John E. Skvarla, III
Director Secretary
Name of Authorized Agent or this project:
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Agent's Mailing Address:
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Phone Number
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
For my property located at '3 _ i- c_G (c
ce
I\bi(N.CuYO1,ua.
This certification is valid thru (date)
Pr erty Owner lignature Date

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Date Received
Date Deposited
Check From None
Name of Permit Holder
Vendor
Check NumbM
Check amount
Permit NumbWCommenls
Receipt or RefuMrReallocated
10/26/2017
Grice Construction
Gary D. Angel
BBBT
11618
$200.00 GP 68566D
$200.00 GP 68565D
SF rot. 5334D
10/26/2017
Grice Construction
Walter Kowtoniuk
BB&T
11617
SF rct. 5333D
SF rct. 5330D
10/26/20171
H5 Construction
_
Moretha Wilson Hinson Stankard
BB&T
2077
$200.00 GP 68563D