General Permits (7202)

�O
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 #S)
Address___ '`" it '7— /
City r;
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 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
(SCALE: j
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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
40evelopm ent.
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
AX
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT (FOR A PIER)
I hereby certify that I�{own property adjacent to�Y eAIf- I
property located at I —
(lot, block, roa : etc.) /
on 0— QA (.le Z in N.C.
(wa r body) ( own 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. I understand that a pier must be set back a
minimum distance of 15 feet from my area of riparian access unless waived by me.
I doCono i� ��waive that setback requirement.
(circle one
Description and/or drawing of proposed development: (to be filled in by individual
proposing development)
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Signa ure
Name
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Phone Number

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT (FOR A PIER)
I hereby certify that I own property adjacent to :,I'll Lr-e_ylc-L rVf—'C ' '
property located at `--ALL Ce
p� (lot, block, road, tc.)
in N.C.
( ter body) (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. I understand that a pier must be set back a
minimum distance of 15 feet from my area of riparian access unless waived by me.
1
I do / do nod' wish to waive that setback requirement.
(circle one)
Description and/or drawing of proposed development: (to be filled in by individual
proposing development)
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Signature
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Name
Phone Number

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GENERAL PERMIT APPLICATION INFORMATION
APPLICANT'S NAME:
E Lj c� � IP
R�a n
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KKtC N I t-C,
(First)
(Middle)
(Last)
(WING ADDRESS:
S- C-LL(j3
_
C1
(PERMANENT)
[_otQ'F
STATE C-
ZIP SAS'
TELEPHONE:
WORK ( ` _)
HOME (JLt_) 7
J 3 &L�
CONTRACTOR'S NAME:-&C- TL"f5r- ,j1tA-
00t: C'ONSi-
TELEPHONE NUMBER
PROJECT LOCATION:
N.C. Hwy.
SR 4/ Road/Street Name CL V�$
C`TT,
Waterway Name MAP
"()F CJqIVAL
CountyT-
Town CIVE5
Subdivision CLf. Xl`Ygl
,J CU kB
Opp Iq Clr
PROJECT ACTIVITIES:
PIER: Total dimensions of pier from MHW to platform
(Length) (Width)
'T' or 'L'-head platform
(Length) (Width) (Number of Mooring Piles)
Water depth at end of pier Number of Mooring piles
HOUSE/BOAT LIFT: Length j �3 ! Width
Number of Piles Water Depth 3
BULKHEAD: 1/1 Total length
Average distance waterward MHW
Maximum distance waterward MHW
(/2 Total length
Average distance waterward MHW
Maximum distance waterward MHW
RIPRAP: Total length
EXCAVATION: [MAINTENANCE 'ONLY']
Base width from MHW
Length Width Depth of Cut
Adjusted water depth on MLW Existing water depth(s)
Estimated Cubic Yards (length x width x depth/27)
is Type of spoil: Sand Mud
Dragline Backhoe Hydraulic
OTHER STRUCTURES:

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