11767_KELLER, GORDON_19930416

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CAMA AND DREDGE AND FILL
GENERAL 11767
PERMIT ra�
as authorized by the State of North Carolina
Department of Environment, Health, and Natural Resources and the Co"l Resources Commission
in an area of environmental concern pursuant to 15 NCAC / /r e/ _
Applicant Name f ��� `� r Phone Number } q
Address
City . of // (I ,�•} CIO
Project Location (Count, State Road, Water Body, etc.) —
Type of Project Activity
PROJECT DESCRIPTION I SKETCH
Pier (dock) length
Groin length
number
Bulkhead length
106.
max. distance offshore
Basin, channel dimensions
cubic yards
Boat ramp dimensions
Other
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,
imprisonment or civil action; and may cause the permit to be-
come 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) this pro-
ject is consistent with the local land use plan and all local
ordinances, and 2) a written statement has been obtained from
adjacent riparian landowners certifying that they have no
objections to the proposed work.
State ! �^ Zip % 1-) / 0
,l�yLT!u mac:
f
__.._.(SALE: )
,/,lID-, iU Ir i79 T C s
�j applicant's signature
permit officer's signature
issuing date expiration date
attachments
In issuing this permit the State of North Carolina certifies that U
this project is consistent with the North Carolina Coastal application fee
Management Program.

H f. STACY A. KELLER FIRST CITIZENS BANK
ROBERT S. KELLER & TRUST COMPANY 1786
NCDL 5414537 249-0058 BAYBORO. NC 28515
Ldti�
P.O. BOX 527 CRAYTON BAY 66-30/531 - 85O
PAY TO ORIENTAL, NC 28571
Date
THE ORDER
1
F.
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MernbND .I. F-iN E'-:TATE'=; CAMA PERM I T
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1786

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that -I
Name
located at
property adjacent to
-A 0 Cry
's property
. on
(Lot, Block, oad, etc.)
�zr'JSC ki Ver' in /P�� 4 It- Gy N.C.
(Water Body) (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 must be set back a minimum
distance of fifteen feet (15') from my area of riparian access
unless waived by me.
L--- I do not wish to waive that 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)
Signature'
(/.p ►"coo lei �� (Tr
Name
�z Y�F' 11'q
Phone Number