General Permits (5350)

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CERTIFICATION OF EXEMpj 97 )'
FROM REQUIRING A CAMA PERMIT -
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources an� ssion
. in a ,Irea of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name _j U�r` Phone Number
Address " L 0- r
City l -, v State <y. Zip 2
Project Location (.County, State Road, Water Body, etc.) t'" i 1-�
Type and Dimensions of Project i e _ V,<,J a ILI . .
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.
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llskllwila�Wl /-
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.
SKETCH r-- , } (SCALE:
"Oct I
----
I V.
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.
CAMA Officials ignature
. � 1.
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative`Code 7K .0203