HomeMy WebLinkAbout75804D - Atkinson)(CAMA / 7, DREDGE & FILL NO. 75804 A B C
GENERAL PERMIT Previous permit#
)(New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality �� 114`lJ�
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
❑ Rules attached.
Applicant Name Fr""
FrA" k �7 Wl'h Sb ►'\
Q
Address I & &P•4^Qe\s eV Rd SVJ
Project Location: County �r �t►� C w lL� a/
Street Address/ State Road/ Lot #(s)
City S u State NL zip
Phone # )5 7 6 -Mail io GLAV ► kp 'fubdivision
Authorized Agent C7f lq �oi�e.V1 City t zip
Affected ❑ CW )(EW XPTA
AEC(s): ❑ OEA ❑ HHF ❑ IH
❑ PWS:
ORW: yes /ro )
❑ ES ❑ PTS Phone # ( River Basin L U w+ pe"
❑ UBA ❑ N/A Adj. Wtr. Body L t, c-k-W S r'�% �tt'� nat)/man /unkn)
PNA yes / no Closest Maj. Wtr. Body
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Signature reaU compliance statement on back of permitit;Oltaie
no - 3S a-!�
Application Fee(s) Check #
&YlBri'(NV_
Per 'Officer's 4Prildl Name
Signature
LiI � �O
Issuinj Date Expiration Date
AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: F. t\ (4+ �< 1 Y) �'o n
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
L rf1D�'s
ki
*�C4- S~114-"1
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: e e c 4 -�
—r j U a J " \I- 1
d C-
at my property located at q e�� 1 �'S Pt , 1� Q�
in C&-,Qunty.
1 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:
Signature
R, /T-f )�- t' /�
Print or Type Name
Title
V l� l�6
Date
This certification is valid through I I
2nme Of -Individual Appivm-:v , For I
MIEN
m Owl
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fS beimg P"Wmed2 please wrfte itke, DivW,..
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Deb
Check From Name
Name or Nrmm t Hddw
L Vendor
Check Number
Cfrock
amount
P.—it NumberlCwnmente
RecN t w Ref—Waalbceted
Culumni
Column2
Column3 _
C.4-4
I Column#
Cdumn7
Column#
Cdumn9
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_
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_ _
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_
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_
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_
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T
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