89701A - Courd

&atom?"NDCAMA ❑ DREDGE & FILL f`� NU 89701 A B C D
a GENERAL PERMIT Previous permit
3 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:
❑ Rules attached. ❑ General Permit Rules available at the following link: wwvvc1eq.nc.gov/CAMAruIes
Applicant Name
Authorized Agent
Address
Project Location (County):
City State ZIP
Street Address/State Road/Lot #(s)
r
Phone # ( )
"J r7
Email
I
Subdivision 'aX.. � 1' . `J �
z'1
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City V.
zip--,,? 29 3�
Affected ❑ CW 0 EW El PTA ❑ ES ❑ PTS Adj. Wtr. Body r-( i.i + S (pat/man/unk)
AEC(s): ❑ OEA ElIHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body ! - i ;.• ;.
ORW: yes/no PNA: yes/nci
Type of Project/ Activity
(Scale: �;`>)
Shoreline Leneth �r"l)
Access Length
ME
..Total
Pier (dock) length
Fixed Platform(s)
I
M
Floating Platform(s)
Finger pler(s)
If
Platform area 9
ME
Breakwater/Sill
Max distance/ length
Cubic
I
yards
'oat ramp
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;AV observed: yes 1�6
Moratorium; n/a yes n
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'iparian Waiver Attached: Ak no■
A building permit/zoning permit maybe 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 M/Money Order
Signature
Issuing Date
Date

'' ^ +,IVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
S
I certify that I have authorized (agent) //a,1-11-i/ :�V / (/� to act on my
behalf, for the purpose of applying for and obtaining all AMA Permits necessary to
install or construct (activity)
at (my property located at)
T4h certification is valid thru (date)
fr4perly Owner Signature
,"e
Date

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