86960A - Gill

❑'CAMA ❑ DREDGE & FILL N° 86960 A ;B C D
Previous permit
3 GENERAL PERMIT Date previous permit issued
N 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:
I SA NCAC ❑ Rules attached. [a General Permit Rules available at the following link: www.deq.ncggv/CAMArules
Applicant Name
City State ZIP
Phone At ( )
r—n
Authorized Agent '
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ cW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtc Body (nat/man/unk)
AEC(s): ❑OEA ❑IHA ❑UW ❑SPIMA ❑PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
(Scale:
■
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.
■
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Avg distance offshore
Max distance/ length-1
Basin, channel
Cubic yards
Boat ramp
B.:..
Beach ..
■
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A�O�rNBreakwater/Sill I
NN
■O
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'COther
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MIND■
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observed: yes no
Moratorium:yesrOO Site Photos:!
Riparian Waiver Attached: yes no
ME
0
MINNS
A1,
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M
OMEN
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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" Signature
Application Fee(s)
Check tt/Money Order Issuing Date
Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit Duane Gill
Mailing Address: 104 Goose Castle Ter
Currituck. N.C. 27929
Phone Number: 757-348-5924
Email Address: [e-mail]
I certify that I have authorized Mathew Sherman
Agent / Contracts
to act on my behalf, for the purpose of applying for and IgCMARC7it �we gan
necessary for the following proposed development:
dock and boat lift
at my propeRylocated at 104 Goose CAstle Ter
to CYurritucr-kan
ty.
0
1 furthermore certlly 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. i
Property Owner IMortnatbn:
Duane Gill
Print or Type Name
Owner
TWO
4 122 123
Date
This certification Is valid through _
Revised Mar. 2016

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