59152D - Davis

CAMA / - DREDGE & FILL
GENERAL PERMIT Previous permit#
New .__.Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
prized by the Stke of North Carolina, Department of Environment and Natural Resources
Coastah Resources Commission in an area of environmental concern pursuant to 15A NCAC r H ZDy
❑ Rules attached.
nt Name ALAIV DAV 15
("T)tci jsiocyt) �n
'PrLi✓ 1l�•i-�- State NC_. - Zip 27/ 1 --
0 Fax # ( )
zed Agent
CW Z2 EW 'PTA ES ❑ PTS
OEA _ HHF IH ❑ UBA ❑ N/A
PWS: ❑ FC:
Project Location: County
Street Address/ State Road/ loot #(s
Subdivision
City ✓eOr` !�(Ty? ZIPS
Phone Riveerr^Basin
Adj. Wtr. Body �iAv�,4 A._ir/ 6V nat
yes /, no PNA yes Crit.Hab. yes / Closest Maj. Wtr. Body
►f Project/ Activity 5 tA j riUaY I�
(Scale:
ock) length
ength
umber
ad/ Riprap length_
✓g distance offshore
iax distance offshore
:hannel
jbic yards
unp
Boatl'�, �z
Bulldozing
-�
ss
ne Length
not sure
yes
no
gs: not sure
yes
no
,rium: n/a
yes
po
yes
no
Attached:
yes
no
ling permit may be requin

klc.wj
A i
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
el F. Easley, Governor Charles S. Jones, Director Wiliam G. Ross Jr., Secretary
Authorized Agent Consent Agreement
NT 1 ttii(112.1 W 1�151 �-U C�"! D�N is hereby authorized to act on my behalf
(Printed Name &Ageno
�r to obtain any CAMA permit(s) required for the property listed below. The authorization is limited to the
c activities described in the attached sketch.
TION OF PROJECT:
10 U ?) CAIV, a-
ERTY OWNER MAILING ADDRESS:
S66 CAwate., 'iL s n—
cAe-Lk�'_tvC , "'�7)6 kZ PHONE NO. ILN:5
DRIZED AGENT MAILING ADDRESS:
s iI N ` ly-i Cots-tw -in p M
AWD
PHONE NO. 0 —
`ure of.Property Owner.

4TI N 0 P,I CONS V CD V N
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1
plicant: Permit #: L
te:
•
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ind in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
)itat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts)
amount)
Dredge ❑ Fill ❑ Both ❑
■ 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:
I1� I�Inc'10A A \[L
V4vv\A- Dl> t NG 43(f5
l
Ts delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
❑ Certified Mail ❑ Express Mail
❑ Registered ❑ Retum Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
L
_ 2. ArtkleNumbw 7011 3500 0001 3954 5978
(rmnsfer bom service ►abeq
_ PS Form 3811, February 2004 I Domestic Return Receipt 102585.02-M-1540
Dredge ❑ Fill f-1 1
Both f-1 Other 0 1
■ 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:
A. Signature
Xn ,.
❑r.
B� R ed (PHntW C.�e�ee Ivery
D. Is delivery address cliff t from item 1? ❑Yes
If YES, enter delivery address below: ❑ No