61700D - Cook

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"ENERAL PERMIT Previous permit#
lNew ❑Modification Complete Reissue ❑Partial Reissue Date previous permit issued
rized 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
ules attached.
t Name C fJ0 Project Location: County 6�>Lv1 t
i -L 10 Stree(t,Address/ State Road/ Lot #(s)
Stat ZIP T J I"��' v .' v-,4 j tVth 'V6
"=,,lax# (( )Subdivisioed Agent1"t�i� t City4Alt 6f
CW ❑ EW W PTA ❑ ES ❑ PTS Phone # ( )
r ..
OEA J HHF ❑ IH ❑ UBA C N/A Adj. Wtr. Body
PWS: ❑ FC:
yes / no PNA yes / no Cril yes no Closest Maj. Wtr. Body
)f Project/ Activity
ock)
ength
umber
ad/ Riprap length_
✓g distance offshore
iax distance offshore
:hannel
ibic yards
MID
use/ l3oatlih ) Z
34dozing
RAW H; f�`
ne Length
not sure yes no
ws
gs: not sure yes no
,rium: n/a yes no
_M yes no
Attached: yes *o
ling permit may be require
ZIP
River Basin
(Scale: .

;-Divis on of Coastal Mgt, Habitat impact Compeer Sheet
iicant: Ak Gcot Permit #:
e:
JPyvkiz
z r3
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd in your Habitat code sheet.
�itat 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
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
❑ Fill ❑ Both ❑ Other
tDredge❑ 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 ❑ Other ❑
3o ::� M V" 10

1212
ICTION INC 65-112/531
701
pate
$
Dollars ❑� o::�»»
ANY
5LO92 194711'01212 ��

764 - �6 ?- (-.,,
rz
0
4e
1 1 2-1
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North Carolina Departrlerrt of E-n0twrrient and NavalResourceS
Division of Coastal*-riagen'+
Beverly Eaves due James H. G*wn
Governor Director
AGENT AU I TION F M,
Dale: �
Blame of Property Ovfw for Permit
5
Owners MaUing Address:
(fig
Phone. NLimber 36/<E"-.7- 4""'
Dee Freeman
Seretary
Name of Asflorized ent for this project
Agent's Maikng Address:
Phone Number
certify. that J have authorized the agent listed above to act on my behalf, for the Purpose of applying
for and obtaining all CAMA
(my property located) at 14_ Q yRr �- lJ
to instsll or QOMryct the foUQ" (ac"uvny)-
Thia cgrWi -,aftm is valid thru (date)
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