59223D - Peters

59"
CAMA / ❑ DREDGE & FILL
'IENERAL PERMIT
Previous permit #
New ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
ized by the State of forth Carolina, Department of Environment and Natural Resources 1'
:oastal Resources Commission in an area of environmental concern pursuant
to 15A NCAC
ales attached.
t Name Yz
Project Location: County
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Street Address/ State/Lot #(s)
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❑1 IJ7
( ) 10 Fax # ( )
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ed Agent 1� �,iS
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❑ CW EW C].PTA ' ES ❑ PTS
P'l ne # ) ` 12-1
River Basin
❑ OEA /❑ HHF ❑ IH UBA ❑ N/A
Adj. Wtr. Body
yes CIO_ PNA yes no Crit.Hab. yes / no
Closest Maj. Wtr. Body J�
IhJ
' Project/ Activity
ngth
tuber
d/ Riprap length
distance offshore
uc distance offshore
cannel
bic yards
np
ise/ Boatlift
e Length
�+
not sure yes no
s: not sure yes no
-cum: n/a yes no
yes F�n.
Attached: yes
ing permit may be required by:
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(Scale:
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North Carolina Departrnent of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson Dee Freeman
Governor Director Secretary
AGENT AUTHORIZATION FORM
Date:
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
/ c'lGi e f� �r� r I �i v !►'1 k s fir Gi; �c t, rh c 6� I 1c�i'l S
owner's Ma fng Address: 1 VU 9)1 c rP sI ZA1
�1 c7c7 2 tl
Phone Number
Agent's MafHngAddress: /11
Cr is lG`t taxi
A) f
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Phone Number (`,%S—
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
fit' �G=c e0 it
(my property located) at L/ �Ct� �LrY� t /� <<' /�"`
A/L
This certification is valid thru (date) 7/ -3,-) J��
T ' Property Owner Signature Date
127 Car&W Drive EA, NCd &ow. NC 2W
mane_ 910.796.72r51 FAk 910395.3W Ww*t www.
AnEqual omon+ar l AllcminAdam E00"d
No a Carolina
urally

licant o P'o �PP � I dY<—
gate: r ` O r
Permit #: 5� 2z3 o
escribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
fund in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
ibitat Name DISTURB TYPE Disturbance total
disturbance.
Disturbance
disturbance.
Choose One includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
I
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts)
amount)
Dredge ❑ Fill ❑ Both ❑ Other
■ Complete items 1, 2, and 3. Also complete
Rem 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:
Ce C-i / J/a /I(prs
�V6 40Ra r-�- )U
2. Article Number
(Transfer from service lab% ? 010 3090
PS Form 3811, February 2004 Domes c
Dr -' SENDER: __
COMPLETE•
D
■ Complete items 1, 2, and 3. Also complete
Rem 4 if Restricted Delivery is desired.
Dr ■ 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,
Dror on the front if space permits.
1. Article Addressed to:
A. Si ture
X ❑ Agent
Addressee
B Received by (Prin me) C. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Service Type
❑ Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
0001 1220 6581
""Now -
A. :'Qma
X , 2
102595-02-M-1540
❑ Agent
❑ Addressee
B. 7eived by (Print Name) JC. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
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