General Permits (4217)

1 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 Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name
Address
City - -
Project Location (County, State Road, Water Body, etc.)
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 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
State
Zip
This ccrtification 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.
SKETCH (SCALE: )
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 been obtained from adjacent
landowners certifying that they have no objections to the
proposed work.
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Applicant's signature�,�+WM1/_� s ^
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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Location: } Field Fe-p. (G�
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Phone: �j -D — � `�� Date of P.eport:
Description of Project:
Date Project Reportedly Comp7`'ete:
(1) ' Do the measured dimensions of the developmenf 'iffer frori those
indicated in the permit .and,%wo kplat?, Yes / ro Have all permt
conditions been satisfied? 'Y s / No
1. COY-MENT :
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(2) Sedimentation an(f Fresion Control: Has pern'wlt�== Sc=dc CraSSc��
or cCerlse sta�.i1iZed all C1Sturbed areas: IYc= NO r
CO2P'H^ NT :
(3) Future MOnitcrinQ and rnfcrcenent P_C' n: ISTfur�._er inVEStiQaticn
or enforcement action needed? Yes /r N
COi'�� NT