76467D - Long

]CAMA/ El DREDGE & FILL 76467 A B
3ENERAL PERMIT Previous permit# 2-S-
NNew _Modification ❑Complete Reissue El Partial Reissue Date previous permit issued /2/
-ized by the State of North Carolina,Department of Environmental Quality -7
:oastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC 0 T r(• 2 5oQ
Li E Rules attached.
t Name ,t( i A •ti- L v". Project Location: County (. ".3 ,jc__
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Street Address/State Road/Lot#(s) SA�E A
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ed Agent ,cL— Li e S City ZIP
pCW ❑EW ,PTA ❑ES ❑PTS Phone# ( ) River Basin (0,.1y
❑OEA ❑HHF ❑IH ❑USA ❑N/A
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Attached: yes '
ng permit may be required by: S+iAs_j 1>(AC c, H See note on back regarding River Basin r
I nral Planning Iurisrlirtinnl

AGENT AUTHORIZATION FOR CAMA PERMIT APPUCATION
Name of Property Owner Requesting Permit: LAL,‘ Am L oN Q�
Mailing Address: `a 1\_‘crl+ c'Q, U1
Phone Number: Z � L
'
Email Address: i-J1 �fV� 1J�^1 t►..,�1, • C cv
I certify that I have authorized �l I`c—�.�P—s d %ton 4.) Jc)c- CS
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining- all CAMA permits/
ta
necessary for the following proposed development: 1- > It) 11k.L)/
s P '
at my property located at
in >^u S County.
I 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.
Property Owner Information:
Signet
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Print or Type Name
Title
Date �Z�

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