61639D - Rojanatavorn

CAMA / DREDGE & FILL
6`3ENERAL PERMIT
Previous permit #
New Modification Complete Reissue El Partial Reissue
Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
H. 120 0
t Name �,Sft UO PC)SATA O
Project Location:
4-.?Rules; attached.
County t_.4
u -.
Street Address/ State Road/ Lot #(s)
State ZIP :
G,Uf A
k"Ni Ai-L i f' h-A P?-.
Fax # ( )
Subdivision
zed Agent
City('�"&V'
ZIP r��3
d - CW _ EW -PTA J ES ❑ PTS
Phone # ( )
River Basin
OEA HHF ` IH ❑ UBA ❑ N/A
Adj. Wtr. Body
!?�t�Ii Cj (�'�'_�(nat
PWS: FC.
yes / no PNA yes no : Crit.Hab. yes / no
Closest Maj. Wtr.
Body , \ i l V
3f Project/ Activity �_i _ i V,
(Scale: Sys
lock) length A, I % K
m(s)
pier(s)
length
umber
!ad/ Riprap length
vg distance offshore
iax distance offshore
channel
ubic yards
Imp
,use/ Boatlift
Bulldozing
J
ne Length
not sure yes no
gs: not sure yes no
,rium: n/a yes no
ling permit may be required by: ❑ See note on back regarding River Basin

Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
-labitat 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
onor
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/o
temp impact
amount)
/
Dredge ❑
Fill ❑ Both ❑ Other.
Dredge ❑
Fill ❑ Both ❑ Other E4f
Q
�P
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 ❑

■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ 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 Addressed to:
I""a-.1 I A i W ►+ V /' -f
A. �nz� I^`� KN �.J�X El Agent
❑ Addressee
a R [y
ived (P/rin ed Name) C DDate of%eWery
�,. r V
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No

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