76509D - Osborn

CAMA / ❑ DREDGE & FILL N° 76509 A B
iENERAL PERMIT Previous permit#
flew ❑Modification El Complete Reissue El Partial Reissue Date previous permit issued
zed by the State of North Carolina, Department of Environmental Quality 010 i , -2_ (, v
Dastal Resources Commission in an area of environmental concern pursuant to I SA NCAC ❑ Rules attached.
Name Project Location: County —
Street Address/ State Road/ Lot #(s)
L (' L State N L ZI � �' � ? �� � ��1�-' ►n S f�%� _
Subdivision
E-Mail
W Agent
1 rn �� V J� j 1 ( City E � -� �4 ZIP
❑ CW EW IOTA ❑ ES ❑ PTS Phone # ( �r River Basin V v
❑ OEA HHF ❑ 1H ❑ USA ❑ N/A Adj. Wtr. Body ` 'A (6?:� w
Closest Mai. Wtr. Body
yes(no> PNA y t`�
�<
' Project/ Activity
ck)length
itform(s)
ngth
tuber
d/ Riprap length_
g distance offshore,
ix distance offshore
hannel
bic yards
'n I
fset Boatlift x
ne Length ` I -
not sure yes
Irium: n/a yes
yes
'l,
(Scale:
Attached: /yes In
ling permit may be required by: r` ❑ See note on back regarding River Basin

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
4
sCj F C f Nay y
CVO
Agent /
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:tJ���=•-
II-!rfi
at my property located at )'i i /� �- L� ► v�-s d '
in <? h q V— County.
I 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:
C� ►r'v�
Signature
Print or Type Name
Title

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 7DO r s
�i (Name of Property Owner)
property located at % 77 i- % i ✓ys d 1<-
L (Address, Lot, Block, Road, etc.)
on �h4fV- CEaal5f'-1 , in-5-c.,"-� 0 1+1 P �cf �vC�'�AI�C.
(Waterbody) (City/Town-kid/or County) ✓
The, applicant has described to me, as shown below, the development proposed at the above locatic
V I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must till in description below or attach a site drawing)
IT C-1- P-N A -B C� CIL I
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set b�
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to v
the se back, you must initial the appropriate blank below.)
J4� I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjac Property Owner Information)
ature` Signature
Cc �f�17 ✓' r•
PrIJ tt or Tye Name Print or T pe Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 7)0 s
1Name of Property Owner)
property located at
(Address, Lot, Block, Road, etc')
(Waterbody) (City/Town and/or County) toc.
,d
The appli t has described to me, as shown below, the development proposed at the above location
� 1 have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
3 oc-i< 61P--% CA 3© C%-'� I- I 3
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bad
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wa
the setba 1you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement.
(Property Owner Information)
2L-Iga
ature
Irit or Ty e Name
�1 x*+ 1� ✓�s t� r R
(Adjacent Property Owner Information)
Signature
Print or Type Name
I:

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