69219D - Landretto

CAMA / ❑ DREDGE & FILL A B
'ENERAL PERMIT Previous permit #
klew ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
•ized by the State of North Carolina, Department of Environment and Natural Resources �� C' b
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC ❑Rules attached.
t Name tC, �' l� kp��-_L�"''n Ate f 1 0 Project Location: County_&nS IA T
z o p W o Vs 9- d' - Street Address/ State Road/ Lot #(s)
z•�(/1Ca State_{ ZIP T7' (J S
(JSC� u OV7 f�0 E-Mail Subdivision
.ed Agent City_ (2AJA S NCB ZIP / o "
❑ CW TA El ElPTS Phone (� I �) 4 q ?--O River Basin l IAV
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body (nat /
❑ PWS:
Closest Maj. Wtr. Body
f Project/ Activity
. ampk�
)ck) length
latform(s)
Li
Platform(s)
pier(s)
ength
ember
ad/ Riprap length
✓g distance offshore
iax distance offshore
:hannel
ubic yards
imp
)use/ Boatlift
line Length )U
not sure yes o
:orium: n/a yes
s: yes
;r Attached: yes
(ding permit may be required by: �� b OC�Q��C A,(
❑ See note on back regarding River Basir

■ Complete items 1, 2, and 3.
■ 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.
1. Article ddressed to:
3 3 iVyl,i,oli yo/%
Oc-
A.
❑ Agent
❑ Addressee
B. Received by (Punted Name) C. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: p No
IIIIIIIII IIII IIIIIIIIII III IIIIIIIIIIII�iIII III 3. Service Type
❑ Adult Signature
❑ Adult Signature Restricted Delivery
9590 9402 1364 5285 8914 80 0 Certified
dd Mail Restricted Delivery
❑ Collect on Delivery
2. ` Transfer from service label) ❑ Collect on Delivery Restricted Delivery
0 Insured Mail
7 015 0920 0 0 0 0 7 61 ❑ Insured Mail Restricted Delivery
0 4 2 _
❑ Priority Mail Express®
❑ Registered Maii'M
❑ Registered Mail Restricted
Delivery
❑ Return Receipt for
Merchandise
❑ Signature Confirmation-
0 Signature Confirmation
Restricted Delivery
PS Form 3811, July 2015 PSN 7530-0 - - 6 4
Domestic Return Receipt

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
►ry Braxton C. Davis
r Director
John E. Skvarla, III
Secretary
AGENT AUTHORIZATION FORM
Date:_
'roperty Owner pplying for Permit: Name of Authorized Agent for this project:
failing Address: Agent's Mailing Address: _
mber (336) - Y4/G7& Phone Number ( 7 02' % %�'i 3
at I have authorized the agent listed above to act on my behalf, for the purpose of applying
ning all CAMA Permits necessary to install or construct the following (activity):
operty located at
cation is valid thru (date)
Iroperty Owner Signature
Sr
Date