66661D - Ruff

LAMA / ❑DREDGE &FILL A B
iENERAL PERM I Previous permit#
,4ew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
zed by the State of North Carolina, Department of Environment and Natural Resources -- t i � a, --)
)astal Resources Commission in an area of environmental concern pursuant to I SA NCAC {-� ❑ Rules attached.
Name . � �.i'' Project Location: Coun��-
L 6 �� Street Address/ State Road/ Lot. #(s)
State ZI c-'
E-Mail Subdivision 6
/ CitY. ZIP
:d Agent / c ' � j
❑ CVi/IV A ❑ ES ❑ PTS✓ Phone # (-7 River Basin
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ WA Adj. Wtr. Bod ' nat n
❑PW Vv
Closest Maj. Wtr. Body
yes no PNA yes no
P■��
Project/ Activity
:k) length X
itform(s)
Platform(s 'A
ier(s)
ngth
tuber
d/ Riprap length
distance offshore_
uc distance offshore
cannel
bic yards
np
ise/ Boatlift
Bulldozing f
ie Length 1 is
not sure yes
mum: n/a yes
yes
0
53
(Scale:, L'
Attached: yes ( no
ling permit may be required by:
a Local Planning lurisdiction)` ,
t ❑ See note on back regarding River Basin f

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: �� � ,l �— PE'1'Cillt
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.
iabitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL. Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet F1NAL feet
(Applied for. (Anticipated final
Disturbance disturbance.
total includes Excludes any
any anticipated restoration and/or
restoration or temp impact
temp impacts) am nt)
bwDredge
❑ Fill ❑ Both ❑ Other
�G k.
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge.❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both Other ❑
Dredge ❑ Fill ❑ Both 0 Other ❑

2l T��
N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of (Property Owner Applying for Permit:
j
\ e- k -P— L L C,- 'G, :Ru--f2
Mailing Address:
Cam -
reer)v // Scf—` �dOl
1 <
I certify that I have authorized (agent) '/C to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date)
a
Property Owner Signature
)U (�-,
Ix