General Permits (8166)

-Y- 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 t 15 NCAC Subchapter 7K .0203.
Applicant Name/ e �i' 6?/ Phone Number* �
Address '16Z 777/
City ,1,q State Zip 23
Project Location (County, State Road,. Water Body, etc.) 4 eAL,
�.,
Type and Dimensions of Ptoiect err.' _ G� i �a ! - 3�►?z- C- -�.. �%" ` "
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.
I SKETCH (SCALE: ) I
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
velopment.
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.
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
N
located at
's property
on
(Lot, Block; Road, etc.)
in 41'a , N.C.
(Wat r 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. IL
p�
I do not wish to waive that setback requirement.
I do wish to waive that setback requirement.
Description and/or drawing of proposed development: (TO BE
FILLED IN BY INDIVIDUAL PROPOSING DEVELOPMENT)
r
I
i
Si natu e
( i
Nam— e
9 1 q 13
Phone Number
I
r
I

ADJACENT RIPPRIAN PROPERTY OWNER STATEMENT
(FOR A PIER)
I hereby certify that I own property adjacent to
Name
f
located at Mo 2-
is property
, on
(Lot, Block, Road, etc.)
in a P , N.C.
(W$?ter ody (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. id
I do not wish to waive that setback requirement.
I do wish to waive that setback requirement.
Description and/or drawing of proposed development: (To BE
FILLED IN BY INDIVIDUAL PROPOSIhU--DEVELOPY-ENT)
i
� I
Signatu e
Name
.2 7 `_3 g 1k
Phone Number
ti

GENERAL PERMIT APPLICATION INFORMATION
APPLICANT'S NAME:
r GG �ce(J
,(� it '�� lifrftiL 9.C,—
KK ADDRESS:
(First)
�p O�� ; 4-,*
'(Middle)
(Last)
(PERMANENT)
'Of
t
STATE GY
TELEPHONE: WORK (�
HOME ( )
CONTRACTOR'S NAME:
TELEPHONE NUMBER
7-r- (o _ y_, , ? cq
��
6 - t
PROJECT LOCATION:
N.C. H # J-"
SR 4l Road/Street Name r/ a `L
G
Waterway Name
County
Town
Subdivision
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,
HOUSE/BOAT LIFT:
Length
Number of Piles
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']
Length Width
Number of Mooring piles
Width
Water Depth
Base width from MHW
Depth of Cut
Adjusted water depth on MLW Existing water depth(s)
Estimated Cubic Yards (length x width x depth/27)
• Type of spoil: Sand Mud
Dragline Backhoe Hydraulic
OTHER STRUCTURES: _J�'