89639A-Kellum

°"°"".°` ❑CAMA ❑DREDGE & FILL N9 89639 9' A B C DV
GENERAL Previous permit
PERMIT
Date previous permit issued
❑New ❑Modification ❑ Complete Reissue ❑ Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
15A NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: www.dea nc gov/_ CAMAr+ules
Applicant Name
Address
City State
Phone # (_ )
Email
ZIP
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ CW ❑ E W ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (nattman/unk)
AEC(s): ❑OEA ❑IHA ❑UW ❑SPIMA ❑PWS Closest Mal. Win Body
ORW: yes/no : PNA: yes/6o
Type of Project/ Activity
Shoreline Leneth
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No
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A building permit/zoning permit may be required by:
Permit Conditions
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT (Please Initial)
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit'
Application Feels) Check k/Money Order
Signature
Issuing Date
Expiration Date

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