61659D - Black

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IENERAL PERMIT Previous permit# 0-4
New DModification O.Complete Reissue El Partial Reissue Date previous permit issued
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ized by the State of North Carolina, Department of Environment and Natural Resources
oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
❑ Rules attached.
Name fit% G ,% Project Location: County
V(- Street Address/ State Road/ Lot #(s)
. 1 7 State N ,' ZI P I V64 t i 4 L
%) " Fax # ( ) Subdivisiop' Val A'Tc—
:d Agent 7? �",�-{i 6-C..�N .' City I '� 7 i � ZIP Z/����
ElCWW PTA ❑ ES ❑ PTS Phone # ( ) River Basin "F
El OEA El HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body TDf°Sh►C— ❑ PWS: ❑ FC: nat
(es o)PNA no Crit.Hab. yes Closest Maj. Wtr. Body �bP�k �L SOV N%�
es
Project/ Activity h r S
A) IengthLO
(s) j X Z
igth
nber
I/ Riprap length_
distance offshore
x distance offshore
annel
iic yards
1p --
s Boatli Z�
i X 1Z
Aldozing
(Scale: I t =
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=OEM EMEMMEEMMEMEM

All
,pplicant: �/ " l
� Permit #:
late: 17
1 / Y
escribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
fund in your Habitat code sheet.
DISTURB TYPE
ibitat Name 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
(Applied for.
Disturbance
total includes
any anticipated
restoration or
tem impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
ill ❑ Both ❑ Other ❑ll
❑ Both ❑ Other ❑
E
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
:::4Dredge
❑ 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 0 Both ❑ Other ❑

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AGT3357 5 LOC 000183 DT 070913 $200.00 2HUNDREDDOLLARS ANDNO
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RETAIN THIS MONEY ORDER RECEIPT. IT MUST BE INCLUDED WITH ALL REFUND REOUEST . BE SURE T READ IMPORTANT
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INFORMATION BELOW AND ON BACK.
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Order thh time
on, or replace, refund a lost or stolen WUFSI Money Ortler nu Tess I11 yrvu fill'n the face f the Money at of
h the loss or Melt to Western Union F ancur Se Inc. in writing mediateN, tl (3) You provide
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WUFSI wiM this onggnal Voney Order rereipt issued by Western Union Financial Services Inc., Englewood, lurado. For ouatomer
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aemice, call 1-800-999-9660.
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