General Permits (6871)

' s±
y
-�r- 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 c^rtification 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: )
VJ
Any person who proceeds with a development without the con-
sent of a LAMA 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.
Applicant's signature
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARLAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at
cVAMS
(Lot, Block, Road, etc.
�r& `r, t' -r-- 1Yq f:(a n--r)J,."
(Nam of Property Owner)
A10A & k jr a b il,Y
on j U AL 120A—, in �J
Nei i'� v� , N.C.
(Waterbody) (Town and/or County)
He has described to me as shown below, the development he is proposing at that location,
and, I have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development)
A
Signature /
A-1/ ///
Print or Type Name
Telephone Number
Date: �C�

d
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to I %�- 0 1 ; r fy) ""-60Tn'q�
property located at Z- � I 1
(Name of Property Owner) '1
-S J T Mn /i rc- &-r,4,A t Tom' �4
(Lot, Block, Road, etc.)
4
Son -�Cr 01- J , in 7-11EiF ir-L1 UIV N.C.
(Waterbody) (Town and/or County)
He has described to me as shown below, the development he is proposing at that location,
and, I have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development)
nature
Print or Type Name
Al `721� - L,/
el phone Number
Date: ?-- /— a "

AJ,

f
Location: �� Field Fep.
Phone: — % Date of FEport:
Description cf Project:
Date Project Reportedly CompTe- to :
(1) ' Do the me-sured dimensions r� the develcp n differ from those
indicated in the pE wit .and Y __ / N Have all perm; t
conditions been satisfied? C�r)lat?.
COr=NT :
(2)
L _
and Eresi on Control Has
or c ---hez- isE S c_ i l i ZED all Cisturbe'd areas 1
l
(3) Fut,re M'cni tcrinc and ZnforceMent P_
or enfOrcE-iEZlt actions needed? YES- O
C 0 NI
i
IS fu!'"hEr i nvestiaaticn