General Permits (1857)

Applicant Name _
Address
City
CERTIFICATION OF EXEMPTION i
FROM REQUIRING A CAMA PERMIT
B
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and h stal Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subc .0203. _ aG
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Project_L ation (County, State Road, Water Body, etc.)
State & c-
Type and Dimensions of Project ) 0/' i1i 4r, L
The proposed project to be located and constructed as described
above is hereby certified as exempt from the CAMA permit re-
quirement pursuant to 15 NCAC 7K .0203. This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
development is exempted, will be in violation of the CAMA 4 there
is a subsequent determination that a permit was required for the
development.
The applicant certifies by signing this exemption that (1) the ap-
plicant has read and will abide by the conditions of this exemp-
tion, and (2) a written statement has been obtained from adjacent
landowners certifying that they have no objections to the
proposed work.
Zip fir' S
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This certification of exemption from requiring a CAMA permit is
valid for 90 days from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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Dct.13 1,33- 15.04
ACAP TAD TEL [phone] P. 2
ADJACENT RIPARIAN PROPMZTY OWMER STA 7x
I hereby certify that I own property adjacent to
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of Property CK..'nEx) T
(]Ewvs property Iocated at
(Lot, iac Kaad, etc_)
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r h n /f tr-- N. C.
(Water Y) d:r
{TOwn andior county)
He has described to me, as shown below, the development he is
Proposing at that location, and, I have no ob,jc-ctions to his
proposal. -
(To be filled in by xndivi ual prapasing dcvelopnccat)
bulk, Aerod tow &ottS ly/to 'h4ni w;1! AAC/I
eX's iIJQO 601 khena�S 49-A)
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Telephane er
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Oct . 13 " 93.15: @5 RCAF' TAD TEL [phone] P. 3
AWACENT RIPARIAN PROPERTY OWNER STAITE *-WT
I hereby certify that I own properly adjacent to
WIMAM E eRaOJOV AS ptoperty located at
(hi -sae of Property Owner)
Lola 9 !�
(Lot, �loc3e', Road, etc. )
on #4e J e' i t c'f in
(Waterbody) 1 �` e�'—. N-C.
[Town and/or County)
lie has described to me, as shown below, the development he is
Proposing at that location, and, I have no objections to his
proposal. I
DESCRIPTION AND/OR DRAWING OF PROPOSED DEWLOPMENy:
(To be filled in by Individual proposing development)
t JO s i i JO g b u t k h ert d,S ev'iJ A-• A$ 49 ` p ti
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t,o'r a Jt,ar 9 J &or io 1 4.C*r it
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Siana ure
Print of Type NaR%
Telephone Number

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