69024D - Bridger

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NCAMA / -. DREDGE & FILL �� " - e
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GENERAL PERMIT Previous permit# V
:)New Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources , I /� l 1
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC Q� f f � (67 tr, id )
�^_ Rules attached.
Applicant Name �u [�n (F)n C X_('1 ' Project Location: County rw14 `,
Address Street Address/ State Road/ Lot #(s)
City �'L��% State(� 1
Phone E-Mail ` 3 �Wlyh _Subdivision
Authorized Agent City 06e ay, _l. , &A(k zip A O l
Affected ElCww PTA ElES ElPTS Phone # (�� �) % River Basin L
❑ OEA ❑ HHF ❑ IH ElUBA ElN/A
AEC(s): El PWS. Adj. Wtr. Body Al O&Y (o(A /m'_an /unkn)
LA AII./
Age p � ^scant PAnta Name
Sign rem PleapE'readcompliance statement onback ofpermit"
Application Fee(s) Check #
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Permit Officer's Printed a 4
Signature kJ I
7A c) 1-7 c,710A, pl-7
issuingDat xpira on Date

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant:
Date:
Describe below the AABITAT disturbances for the application.
All values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
Habitat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
restoration or
temp impact
impacts)
impact amount)
temp impacts
amount
Itemp
Dredge ❑ Fill ❑ Both ❑ Other
6 C
Dredge ❑ Fill ❑ Both ❑ Other ❑'
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

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Restricted Delivery Fee
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Total Postage & Fees
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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Z /,Z�c 7Z ZI1
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
77
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Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: �
42z°f-
at my property located atCPEh
in j6J' ,I1S1AJl County.
2-9�6 7
I 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
Print or Type Name
Title
C) 3 l�l��
Date
This certification is valid through rZ, SI/1)l