General Permits (3050)

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CERTIFICATION OF EX
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources
in an area of environmental concern pursuant to 15 NCAC
Applicant Name
Address + ('f �` t �C �' i� I f , a t
City
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Proiect Location {County. State Road. Water Bodv- etc-) A rl YJ
Type and D
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.
Phone Number f i i�' " L;, .,) t
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.
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sent of a CAMA official under the mistaken assumption that the
development is exempted, will be in violation of the CAMA if 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.
Applicant's signature, /
CAMA Official's signa ure
I J_ �'
Issuing date r
Expiration date `
Attachment: 15 North Carolina Administrative Code 7K .0203

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