34537_KELLER, GORDON_20030721

❑CAMA / 11 DRED& FILL GE
GENERAL PERMIT Previous permit#
[]New ❑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 Resources Commission in an area of environmental concern pursuant to 15A NCAC
Rules attached.
Applicant Name
Address .
City C i+ r�C ., kC, 1 State ` h ZIP
Phone # (XP) s77)0 ? - i I ( Fax # ( )
r
Authorized Agent -' _ .
Affected ❑ CW M EW O PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑ FC:
ORW: yes /" no) PNA yes / no Crit. Hab. yes / no
Type of Project/ Activity
Pier (dock) length
Platform(s)_i..--
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
I I
Basin, channel
cubic yards
Boat ramp
-
Boathouse/ Boatlift
j
I
i
I
Beach Bulldozing
_
Other k. ! ; r a,:r
it
I
...... ... .... ..
j
Shoreline Length
SAM not sure yes
'no`
Sandbags: not sure yes
w
n/a Yno
�._.....
Phoraoorium:
yes
—
Waiver Attached: yes
i
no
tt
A building permit maybe required by:_a��
Notes/ Special Conditions i0;
R,
'4
C
Agent or Appl'cagi Printed Name
Signature Please read compliance statement on back of permit"
�lODed r^�
Application Fee(s) Check #
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision I k i -
City ZIP
Phone # ( ) River Basin �` U c_
Adj. Wtr. Body r c_ c , 0-at, /man /unkn)
Closest Maj. Wtr. Body—, eA v
(Scale:
❑ See note on back regarding River Basin rules.
l VI Q V//
Cif ESP r ri? e
t` l hl �c, �� icy• ; QAU
0
Issuing Date / Expiration Date
?Y',g 1lf it "-) //7!?-7,�j f �-A
Local PlanningJurisdiction Rover File Name
.�.�-y;►.,nt;lAG:

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that 1) prior to undertaking any activities authorized by this permit, the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s) .
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certifythatthis project is consistentwith the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
❑ Tar- Pamlico River Basin Buffer Rules ❑ Other:
❑ Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Quality. Contact the Division of Water Quality at the Washington Regional Office (252-946-6481) or the Wilmington
Regional Office (910-395-3900) for more information on how to comply with thesebuffer rules.
Division of Coastal Management Offices
Central Office
Mailing Address:
1638 Mail Service Center
Raleigh, NC 27699-1638
Location
Parker -Lincoln Building
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293 / I-888-4RCOAST
Fax:[phone]
Elizabeth City District
1367 U.S. 17 South
Elizabeth City, NC 27909
252-264-3901
Fax:[phone]
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Morehead City District
151-B Hwy. 24
Hestron Plaza II
Morehead City, NC 28557
202-808-2808
Fax: [phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico Counties)
Washington District
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Fax: [phone]
(Serves: Beaufort, Bertie, Hertford, Hyde,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext.
Wilmington, NC 28405-3845
910-395-3900
Fax:[phone]
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
www.nccoastalmanagement.net
Revised 10/05/01

GORDON H KELLER (JR) TRUSTEE 2455
THE KELLER FAMILY TRUST DTD 05-21-93
100 KETCH COURT 66-152/531 CC
ORIENTAL, NC 28571
Date
Pay To The
Order Of _
TACHoyu
Wachovia Bank, N.A.
IL,) Irony, NC 28313
'IV 2
1:0S310 IS 29i: 0780 26073811' 2455
s
.—Dollars 8 °"

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 7t/ / ���,� 's
(Na a of Property Owner)
property located at 3Dl Z
(Lot, Block, Road, etc.)
on /e,"XJ in — "� /Z N.C.
(Waterbody) (Town and/or County)
He has described to me as shown below, the development he is proposing at that location,
and, I have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development)
•
�° ✓� EX `si �'�'�j
r3)
Signature
Print or Type Name
-7s—,2- 1 t -,2
Telephone Number
Date: _ ZA/d 3

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFT/BOAT///) 2HOUSE)/
hereby certify that I own property adjacent to Aee 2'd) 7Z&3�&s
(Name of Property Owner)
property located at lzed' 5zdcjp
(Lot, Block, Road, etc.)
on(iL.eeA ,in ��'jG�Gt N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location,
and, I have no objections to his proposal. I understand that a pier/mooring pilings/boatlift/boathouse
must be set back a minimum distance of fifteen feet (15') from my area of riparian access unless
waived by me.
I do not wish to waive the setback requirement.
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
&X t 5f l 7 �'
3tOR�w �
N
Q
--------------------------------------------------- ---
Signature
`7v w, as C-0 , C tx Ft
Print or Type Name
S,?6 D-? 74
Telephone Number
Date: f *jvL 0_�