69193D - Taylor

(CAMA / i , DREDGE & FILL Q
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"ENERAL PERMIT �`Previous permit #ew L-!Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued_
sized by the State of North Carolina, Department of Environment and Natural Resources
Zoastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
,� p f Rules attached.
it Name AV16� co D , �/`('r Project Location: County �(rl �� 1 rar
,,�Street Address/ State Road/ Lot #(s) � Add,
l
l lakkvO !7 awStateNG zIP?�yea Ci rCGe
( ) E-Mail
:ed Agent 0't(�(-� w R 1
❑ CW EW PTA -ES ElPTS
ElOEA *HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes is PNA yes / 0
Subdivision
City r ( UQA : l I U ((f (V, zip MV
Phone # ( ) tt'/ /70 River Basin
Adj. Wtr. Body h C S i a h rye l nat
Closest Maj. Wtr. Body 2t��V
f Project/ Activity
I KO f u cI,i tti�
(Scale: 111
ng permit may be required by: P'l / (dr lis (! (L ! (a
t[❑See note on back regarding River Basin r
Local Planning Jurisdiction) �

MAGNOLIA
8207 MARKET ST STE P
WILMINGTON
NC
28411-9192
3686410405
/2017 [phone] 12:39 PM
ict Sale Final
iption Oty F'rice
-Class 1 $0.49
r
Domestic)
NILMINGTON, NC 28403)
rleight:0 Lb 0.70 Oz)
:xpected Delivery Day)
=riday 04/14/2017)
ified 1 $3.35
(f@USPS Certified Mail #)
170150640000228464410)--
'n 1 $2.75
Ipt
4@USPS Return Receipt #)
:9590940221446193071785)
$6.59
Card Remit'd $6.59
and Name:Debit Card)
,ccount #:XXXXXXXXXXXX8914)
Pproval #: )
ransaction #:617)
eceipt #:011114)
ebit Card Purchase:$6.59)
ash Back:$0.00)
EN SOMEONE'S MAILBOX. Greeting
available for purchase at s,.iect
ffices.
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UtHTIFIED MAIL° RECEIPT
Domestic Mail Only
For delivery infn—ti-, ,.........-
cur tnumber 3777�
> to gc thehe s latest t �
'd Messaae and Data r;if" mom,

NC Division of Coastal Mgt. Habitat impact Computer SI
plicant: f6 ('PT
te:�j
scribe below HABITAT disturbances for the application.
II 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 fin,
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
abitat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and,
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts
amount)
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 0

Nodh Cardina Department of Ernironmo nt and Natural Resoumm
i7cx�aio R van Jer
Semtaq.
AGENT AUTHORlZATIQN FORM
Date: _21Z`/T
r~e of Rropr Owner ;.,c,F1 y ng for Permit: Name of Authorized Agent for this profec-t_
ner's Making Address:
EmaW:
PhDne �-
tity that 4 have authorized t'le agerri listed above to act on m behalf, for the purpose
y A pose of applying
end obtaining all CAMA Pe --nits necessary to install or construct the f000vAng ;ate y+.
ny Prey located at
xrtific2000 is valid 1 year from (dame) � — � - ��

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2728 North ,
Wilmington, I
phone 910.2
fax 910.256.
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