Crooked Run - 1/8/2019 10:40:54 AM

Submittal Dated: 1/8/2019
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
Existing Project Information:
Rease supply the perrrit nunber for this project.
D# * Permit Namber
SW8181111
Examples: SWxxxxxxx, NO&xxxxx, or NCSxxxxxx
Facility Name:* Crooked Run
County: Pender
Name: Bradley Luckey
Who is submitting the information?
Email Address:* [e-mail]
Please upload all files that need to be submited.
Oick the upload button or drag and drop files here to attach document
Crooked Run_PCN Signed BSL_1.8.19.pdf 53.05MB
Only pdf files are accepted.
Describe the attachments:
Applicant response to request for additional information.
* V By checking the box and signing box below, I certify that:
o I have given true, accurate, and complete information on this form;
o I agree that submission of this Supplemental Information form is a "transaction" subject to Chapter 66, Article 40 of
the NC General Statutes (the "Uniform Electronic Transactions Act)
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the Supplemental Information form."
Full Name:* Bradley S. Luckey
Signature:
Date Submitted: 1/8/2019

Initial Review
Updated ID#: IWORfANT: FEVIBAERSHOLLDVERIFY and revise here if necessary.
SW8181111
Who needs a r Central Office
copy?* V Regional Office
Central Office Reviewer:
Select Reviewing Office*
Wilmington Regional Office — 910-796-7215
Select RO Reviewer:*
[e-mail]