38876_ROSE, LESLIE_20040616 (2)

AMA />tPREDGE & FILL / V
GENEL PERMIT
Previous permit #
�ew ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resour es Commissio in an area of environmental concern pursuant to I SA NCAC C�r • , �i �>✓
I$Rules attached.
Applicant Name s Project Location: County ( ,41) 7 '
Address ~ s / ^� Street Address/ State Road/ Lot #(s) Yy
City *= State ZIP>
Phone # r Fax # (_) Subdivision
4
Authorized Agent' .. �-=r""'`" City A J (hL t � ,� '"i ZIP_ u i
0 CW *W ❑ PTA DES ❑ PTS � Phone # ( f �'a tt� River Basin Lost
s Affected . 0 OEA ❑ HHF 0 IH ' ❑ USA El N/A
AEC
( )• ❑ S: CJFC Ady i. Wtr. Body nat unkn
>.
ORW:' yes /) no PNA yes no Crit. Hab. yes / no Closest Maj. Win Body t .
MEN
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MEMO
-ONE
No
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so
WWAM
MEMO
MEMMEMMIWOMismam
IV,
A-mon
ME
IN
No
SWARM
0
MEN
ON
MOME
0
MEN
No
ME
ME
MENEM
0
OEM
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit **
n.
Ap�tion Fee(s) Check #

Y
LESLIE R. ROSE NCDL 1171751 8 777
AND/OR MARGARET ANN ROSE NCDL 1701325
293 Bayview Dr, Ph 252-728-2868 66-21/530
Harkecs Island, NC 28531 _ BRANCH 77585
Date
Dollars
WACHOVIA
Wachovia Bank, N.A. /
�wachovia.com c.r
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i.053000 2 L91: 105[,64568 L4 28ii' 8 7