56652D - McCullough

LAMA / DREDGE & FILL
GENERAL PERMIT Previous permit#
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P ew _Modification El Complete Reissue El Partial Reissue Date previous permit issued
)rize4 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 f G
C9itt11es attached.
it Name e t rI Project Location: County , 'w I CIle
Street Address/ State Road/ Lot #(s) _�� %�e.✓,�
�.. r'r State:­,/L ZIP
�-11,170` Fax # (
:d Agent _ 1 (2 4�� _ 0
Id G CW EW ❑ PTA ❑ ES L PTS
❑ OEA HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑ FC:
yes / no PNA yes Crit.Hab. yes / no
Subdivision
CiIs' 40 90,oc 1 ZIP 27
Phone # ( ) River Basin Z-&m
Adj. Wtr. Body r,),d ,4 ( w A'/ (nn0'
Closest Maj. Wtr. Body /,V/ ti/ w
Df Project/Activity �PoLA cQ flav�ix . _12
do l /( 9 o o d ) .Jf%,yy 7 4. 7NsI,9 // (Scale: /
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ling permit may be required by:
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❑ See note on back regarding River Basin i

jar
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
overly Eaves Perdue James H. Gregson
)vernor Director
AGENT AUTHORIZATION FORM
Date:
me of Property Owner Applying for Permit:
vner's Mailing Address:
-� v
�r, �j Sig �,-� �, h� v e.
lone Number( a)I(4
Dee Freem�
Secreta
Name of Authorized Agent for this project:
5
Agent's Mailing Address:
�f 70
Phone Number (ol I I ;I—
;ertify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
,r and obtaining all CAMA Permits necessary to install or construct the following (activity):
ny property located) at S g m c) y) r c) -e- S 4— O Phi, -1_75 )-.c-
-his certification is valid thru (date)
­51 nerty Owner Signature Date

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)licant: /?�� ce 4 1` 6, Permit #: e:' ul
L- y//
cribe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen
rid 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 finz
disturbance.
Excludes any
restoration and/
temp impact
amount)
S,L
Dredge ❑ Fill Both ❑ Other ❑
�32
J 7 Z
/
Dredge ElFill ❑ Both ❑ Other
? L
d
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 0 Both ❑ Other ❑

LIMITED RECOURSE:
This Money Order will not be paid if it has been forged,
altered or stolen, and recourse is only against the 441LPERSONAL MONEY ORDER
endorser. This means that persons receiving this
Money Order should accept it only from those known o
to them and against whom they have effective NOT VALID OVER $1,000.00 `
recourse.
EqE
ISSUING BRANCH15062110-4`.. ; ;.' L. .' i TF — l:;i :� Hc•;
DATE t1(tl r —rrj11
PAY TO THE
ORDER OF
RRA F 11�P r ' h
•
•�°t DOLLARS
BT&T,PbCHASER, BY SIG^ YOU AGREE TO THE TEI
P R HA GNE
ADDR
1 � V ` �( �� -_ — _ _ --^ v CITY & STATE
II. 3000 9 S 600 711 1:0 S 140 2 3 6 91:000 10 1908000 1v

■ 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.
In Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to: /
Nj U 1 ^C V c? (j )
A. Signa�turq /
X � Y6 / al' /%/% Cj-mi 0 Agent
Addressee
B. Received by (Printed Name) I C.Aate Qt Delivery
D. Is delivery address different from item 1? ' ❑ Y6`-
If YES, enter delivery address below: ❑ No
G v eS b n ► 3. Service Type
❑Certified Mail
❑Registered
❑ Insured Mail
2. Article Number
Mnn.¢far from
4309
1680 GOD2
3800 8080
PS Form 381 1,a ruary 2004 Domestic Return Receipt
A1111111111111111111111UM11
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
0 Vj
A. Signature
❑ Agent
X ❑ Addressee
B. ecei d by (Print Name) C. Date of Delivery
V
D. Is delivery address different from
5
If YES, enter delivery address below: ❑ No
�S' tad O
❑ Express Mail
❑ Return Receipt for Merchandise
❑ C.O.D.
ktra Fee) ❑ Yes
102595-02-M-1540
3. Service Type
❑ Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
2. Article Number
4. Restricted Delivery? (Extra Fee)
-innR i.kAn 0002 3800 8073
❑ Yes