89348A - Lipinski, Tabitha

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3 GENERAL PERMIT Previouspermp
Date previous permit issued
dNew ❑ 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. []"General General Permit Rules available at the following link: www.deq-nc.gov/CAMArules
Applicant Name _
Address
City
Phone # (_ )
ZIP
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s) i f r tIk l
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City
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Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (nat(man unit)
AEC(s): ❑OEA ❑IHA ❑UW ❑SPIMA ❑PWS Closest Maj. Wtr. Body`! i i�; !i' �,�. „� ��
ORW: yes/no PNA: yes/no
Type of Project/ Activity
(Scale:/y 7- r )
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A building permit/zoning permit may be required by:
Permit Conditions
TAR(PAM/NELISE/BLIFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
IAM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT (Please Initial) _. r
Agent or Applicant PRINTED Name
Permit Officer's PRINTED Name
Signature **Please read compliance statement on back of permit**
Application Feels) ' Check #/Money Order
Signature
Issuing Date
Expiration Date
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Doad9n Ern boo ID: DDADOA31-Ed61-4c3 g88"9017&119008
Named ft""Y Owner Requeang pemut: -T"4A-oL ► p iiskA
Mating AddressC of gEAPti ; 4\14 4e,
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