69369D - Coln

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-�. .�'DAMA / DREDGE &FILL
GENERAL PERMIT
-,New Modification Complete Reissue ❑Partial Reissue
Previous permit
A B C (ul
Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources f
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
Applicant Name fit/ 11 i pt o G , (G ( "
Address S boll Vot KA C' V-t /
City � r 7 h ___ State ZIP
Phone # ),- E-Mail
Authorized Agent !A/ (A V1(� Cj h , ��yf �w}1�►(�Din
Affected ❑ CW w PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ URA ❑ N/A
❑ PWS:
Agent or Applicant Printed N}me
A v
Signature ** Please read compliance statement on back of permit **
100,00
Application Fee(s) Check #
n �� _❑ Rules attached.
Project Location: County I V1 &l,%A r L r_
Street Address/ State Road/ Lot #T
Iy.
Subdivision -
City C "(AO fiT�t o�C �n zip Woo
Phone # ( jD) C " G River Basin Woo
Adj. Wtr. Body C6 iA (nat /IQ /unkn)
-rove 51 YYC
PermitOfficer's Printed Name
Signature
d17
Issuing Date Ex iratio ate

Pat McCrory
Governor
C&EN
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Braxton C. Davis
Director
AQf NT AUTHORIZATION FORM
Date:
Name of Prope Owner Applying for Permit:
r "C'
Owner's Mailing Address:
�,KC
Phone Number
John E. 8kmrla, III
Secretary
Na a of Authorized --Agent for this project:
Agent's Mailing Address:
Phone Number L� �) 5-7 R - qGq
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):
i
For my property located at
69
This certification i alid thru (date)
Property Owner Signature Da e
127 Cardinal Drive Ext., Wilmington, NC 28405
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
An Equal Opper4un0y-FAlfinTOve Aclion Employer

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■ Complete items 1, 2, and I
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
Article Addressed to:
rv.
Postal Service'"
:ITIFIFD MOII ® Pl=rriG
Domestic Mail Only '
For delivery information, visit our website at www.usps.com,.
A. Signature
Agent
❑ AddreE
B. R eived by (Printed Nam) / C. D�te^^Died ZI
D. Is delivery address different from item 1? u Ye:
If YES, enter delivery address below: ❑ No
ice Type
0 Priority l Express@
lMail
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III
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❑ dultSignature Restricted Delivery
❑ Registered Restricted
9590 9402 2218 6193 9337 80
❑ ertifiied Mail®
Certified Mail Restricted Delivery
Delivery
LtlwRetum Receipt for
❑ Collect on Delivery
❑ Collect on Delivery Restricted Delivery
_ .
Merchandise
❑Signature Confirmation TM
❑ Signature Confirmation
2. Article Number (Transfer from service label)
7 017 0660 0000 7486
7665 :tricted Delivery
restricted Delivery
Ps Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt I