76520D - Smith

GAMA / ❑ DREDGE & FILL N° 76520 A B
iENERAL PERMIT Previous permit# 22`3
New ❑Modification [--]Complete Reissue El Partial Reissue Date previous permit issued
!zed by the State of North Carolina, Department of Environmental Quality 1
oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC t't0�5 c
es attached.
Namec Project Location: County S g CV
Street Address/ State Road/ Lot #(s)
S, F<��1 State I�II__ ZIP 2cS1 ��..�S�c1� i
'/?U1 Mail pr,� Z �� G����tii�y Subdivision
edggent \c�� cs (City(D .--. ZIP
�bW ❑ EW �a PTA ❑ ES ❑ PTS Phone # ( ) River Basin
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A Adj. Wtr. Body v nat
❑ PWS:
Closest Maj. Wtr. Body
yes / no PNA yes too
Project/ Activity
ck) length
at/f ro m(s) 12 ' Y 1 2 '
f
Platform(s) (PI
:ngth
amber
Ld/ Riprap length_
g distance offshore_
ax distance offshore
hannel
ibic yards
mp
use/ Boatlift 7—
i
3ulldozing
ne Length
not sure yes no
)rium: n/a yes no
yes no
r Attached: yes no
ding permit may be required by:
- 1 ---1 DI---;-- I...ie.dirtinnl
(Scale:
\e- vQ '5� C V ❑ See note on back regarding River Basin

Mail - Brock. Brendan O - Outlook
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address: ,�
t certify that I have authorized (—/� / - lue S -1
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in t''` S County.
l furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Pro/perry owner Information:
Signature
1 U S G t+11 t
Print or Type Name
Title
Date