67255D - McLain

5,C,AMA / Zf DREDGE & FILLQ^ J `,
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�•ENERAL PERMIT 6 Previous permit#
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources � r� ] f� r � `
�oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC llf� �� VD / 7
❑ Rules attached.
It Name b I S C M c L CA► Project Location: County
Street Address/ State Road/ Lot #(s)
✓� 0 2 State
V� ZI P^bh� G :��tjV1
,n -Mail Subdivision
:ed Agent _n{A 1/1 5 f) ,/ City ZIP
d7 Q ZIP?u
❑ CW <I PTA �ES �QPTS7'/�+� Riv Basin
❑ OEA ❑ HHF ❑ IH ElUBA ///❑ 1 N/A Adj. Wtr. Body nat
❑ PWS:
yes / jk") PNA yes /nn Closest Maj. Wtr. Body
F Project/ Activity
'ck) lengt
atform(s)
Platform(s)
:ngth
mber
((diet ncprap length
distance offshore
ix distance offshore
cannel
bic yards
not sure
yes �o
•ium: n/a yes
yes
Attached: yes
V1
1\ k
(Scale: I I
1----4 I I I I I I 1 .i. 1 1 1 I 1 1 J��I e'i !-, 1 1_ 1 1 '..-AI I I i I I I I
ng permit may be required by: - T ayv\ n 1 �u p' n J�'r'c i&q .
Local Planning jurisdiction)
❑ See note on back regarding River Basin r

NC Division of Coastal Mgt. Habitat Impact Con
Applicant:
Date: `
Describe below the HABITAT 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
F
(Applied for.
(Anticipated final
(Applied for.
(/
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
d
Habitat Name
Choose One
includes any
Excludes any
total includes
E
anticipated
restoration
any anticipated
re
restoration or
and/or temp
restoration or
to
temp impacts)
impact amount)
temp impacts
a
Dredge ❑ Fill)J Both ❑ Other ❑
000
l 00o
Dredge INFill ❑ Both ❑ Other ❑
tV
560
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
erly Eaves Perdue Braxton C. Davis
ernor Director
AGENT AUTHORIZATION FORM
Date:
of Property Owner Applying for Permit:
;r's Mailing Address:
7 W,-V
e Number (l� g
Ao�� ,wy
Dee Freen
Secret
Name of Authorized Agent for this project:
7�p-" 5 H�►�vl,e,
Agent's Mailing Address:
Po BOX &Ws
Qt &w, -T5L &acv Xt Z8gV7
Phone Number (243) Z83 - 7tYO-7
fy that I have authorized the agent listed above to act on my behalf, for the purpose of applying
id obtaining all CAMA Permits necessary to install or construct the following (activity):
>
cvi ov �A. 1ov I Lk kLaj-
,y prope y located at �a
;ertification is valid thru (date)
f _C, l77,La'w 10 --14-2d1b
Property Owner Signature Date

SOUTH BRUNSWICK
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RECEIPT
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28469-1029
3669930470
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10/14/2016
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