General Permits (4255)

O
r lJ
CERTIFICATION OF E
q
FROM REQUIRING A CAMA PERM DEC 1 2 ,; I
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resou ommission
in an area of environmental concern pursuant to 15 NCA159Hx4apt".7K.A, Q.,,,,.,..
Applicant Name �Voi
-
Address
City i
Project Location (County,
Road, Water --Body, etc.)
Type and Dimensions of Project I( 1 —
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.
r t ;Phone Number
Zip
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.
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 been obtained from adjacent
landowners certifying that they have no objections to the
proposed work.
Applicants signature �—
I
CAMA Off icial'sisianat re
a
Expiration
Attachment: 15 North Carolina Administrative Code 7K .0203