General Permits (5930)

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CERTIFICATION OF EXEM
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the
in an area of environmental concernryo�ufsr--tewK t9-f AC�Subchapt
Applicant Name /i � , `'!'t; 3
Address /0 3 le-
City�
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Project Location (County, State Road, Water Bod , etc.) _
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Phone Number
State /V C Zip y
Type and Dimensions of Project r r ;4t�'J ate 'J'p d .� f f '+ r/ 'f , - . -'e'/- t e
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The proposed project to be located and constructed as described
above is hereby certified as exempt from the CAMA permit re-
quirement pu-rsuantto t5;» 4�6*0 7-K 0203: This exemption to
CAMA permit requirements do'+~sot alleviate the necessity of
your obtaining any other State, Federaf, or Local authorization.
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SKETCH (SCALE:
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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#corn-adjacent
-landowners.."certifying-. that::they- have no objections '16 the
proposed work.
Applicant's signature
' R CAMA Official's signature
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Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203