General Permits (4190)

Y CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina, /
Department of Environment, Health, and Natural Resources and the Coastal Resou ce C Is1sion "
in an area of environmental concern pursuant to 15 NCAC Subchapter 71st.' 03.
3� l
Applicant Name �s s �`r rir,/-, i' �,Z Phone Num er
Address ' % f''o• r /172
City State x,c Zip s
Project Location (County, State Road, Water Body, etc.) �� n o. , c�/. L�rx 7�, l 37 50,
Type and Dimensions of Project
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-NGAG 7K,-0-203. This exemption to
LAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
J'-
This certification of exemption from requiring a CAMA permit is
valid for90-days from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
I SKETCH (SCALE: ) I
Any person who proceeds with a development without the con-
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 beenobtained from adjacent
landowners --certifying -that- they have no objections to the
proposed, work.
f
Applicant's signature
CAMA Official's signature
Issuing date
_?- ,/ � 7
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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'EN COUNTY NORTH CARD,
3ERT M. CHILES, P.E.
1GINEERS AND CONSULTANTS