Rose, William R.

®GCAMA / ❑ DREDGE & FILL ! �` �' Il, h • t / I ( '' 4 / No. 75232 A B C D
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
and the Coastal Resources Cotnmission in an area of environmental concern pursuant to I SA NCAC
IL Rules attached. �
Applicant Name �` I t j } i (�,_. Project Location: County
City Y\) (t_. \ ;,
Phone
State ` ZIP 1
Authorized Nent
Affected dCW ❑EW IA ❑ES ❑PTS
AEC(s): ElOEA ❑ HHF ❑ ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / no PNA yes / no
St t Address/ State Road/ Lot #(s)
— i
77Subdivision
City_ ZIP_
Phone # (_ ) River Basin
Adj. Wtr. Body (nat /man_ /unkn)
Closest Maj. Wtr. Body
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Application Fee(s) Check #
PermitOfficer's Printed Name ��--
Signature
// 1
Issuing Date' F Expiration Uate

Hurricane Florence and TS Michael
Replacement/Repair Request Form
Date of Request:
Property Owner Name: A//GG/WW1 A, /C7OS
Address of Property: / 8 `� 77/%✓JCS RP, 2-
Telephone Number: Z 5 2 - .S6:.;2 e!9 — Ss
Type of Work: OG"n
NOTE:
• The Emergency CAMA General Permit 2500 is for repairs and replacement of water -
dependent structures damaged because of Hurricane Florence and/or TS Michael. The
replacement, reconstruction and maintenance excavation activities shall conform to
current standards and rules. All work under the Emergency CAMA GP 2500 must be
made in the same footprint of the previous structure with no additions, expansions, or
enlargements.
• If any portion of a structure being replaced is within the 15' setback of the riparian line or
access area, signatures of the adjacent riparian property owner(s) must be obtained
acknowledging the notification and waiver of the setback on the forms provided by
DCM.
• Any maintenance excavation or dredging requires signatures of the adjacent riparian
property owner(s) on the notification forms provided by DCM.
Signature: L2 /R Ro- 2
RECEIVED
AUG 03 2019
DCM-MHD CITY

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