General Permits (8058)

O
Applicant Name
Address (c-�-T
City ! l
Project Location i
CERTIFICATION OF EXP�_I ` ,
FROM REQUIRING A CAMA PERMIT I FEB I i9
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources an � -rhutu be hxrfission
in an area of environmental concern pursuant to 15 NCAC Subd�ept 71�"(7C0�."""--� 1:� Z9 ..• 5 2- 2
r �t`UL'V Phone Number "1 3 7'l 1
State
nty,, State Road, Water Body, etc.) T- t t34,
� i Ae-o Zk-q uC - C
Zip
Type and Dimensions of Project (J e �r w 11cInc (L C4 ! cW_ r,
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.
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:
;Qe dN�clwd
1
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.
Issui ate
E(xpi ation date
Attachment: 15 North Carolina Administrative Code 7K .0203

LAMA
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I HEREBY CERTIFY THAT I OWN PROPERTY ADJACENT TC
15 V III iS — S PROPERTY LOCATED AI'
1 A n R a. A� i Con) '���---- - ON
7 IN
------- N . C .
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
i
F L 6 Ai- r— 4 D cc k
rc-
rEpo
>> ' .-, •, _ per, _.-.
Rip P6p UjftLL
DATE
SIGNATURE
LOT/BLK. NAME PROPERTY 01-INER
TELE HONE NUMBER