General Permits (4603)

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CERTIFICATION OF EXEMPTION - C � r�
FROM REQUIRING A CAMA PERMIT C �>�,-,,� ��•
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 Phone Number
Address 3
City i r 1" State Zip r' it
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.
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.
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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SlJRVL-Y1V!( ._COMPANY
LANIER SURVEYING CO
PAGE 01
„ 19.4.55.3889
Past Of $fix t L3 i Z39 New Bridge Street
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UENTI.EM.EN:
WE ARE SEND[N O, YoU Attached
❑ Drawings t prints
O Copy of letter Change order
COPIES DATE ---
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letter of trarlsmittal
❑ Under separate cover via
❑ Plans a Samples
the following items_
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DESCRIPTION
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THESE ARE TRANSMiTT'st I
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❑ For approval
❑ For your use
❑ As requested
Cl Approved as subm'uc,i
❑ Approved as noted
❑ Returned for corrections
❑ Resubmit
• Submit
O Return . _ corrcc,,i .!
inIS
❑ For mview and commc,?u
❑ For bids due —...- ._
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❑ Prints returned after [gar 1-

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SURVEY MAP
FOR:
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DATE- OCTOBER 6, 1M
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SURVEYING - PLANNING - NAPyy'
239 NEW BRIDGE STREET
JACKSONVILIE. N.C. 28W
[phone]
FAX [phone]
GRAPHIC SCALE
1 fay — 60 it