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CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT P v t,2 14
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. 0'1( h)3 Pt'T Y\e-N-
Applicant Name w , S . ( 4 `�h 1 Phone Number 3 (r. _cs*- U2.1.0
Address y Co U Z Co c("?s-4 &t ex\ is c,rCd
City r State 1\1(.< Zip - 1 i i b
Project Location(County, State Road, Water Body, etc.) l t u(sw'l c L- C 0cA n , 1 s,
Pr ) - tu`r c-1(\ --- P- 1cNON-TN- K.kndf , Cc \
Type and Dimensions of Project .'Srnn 11 , Lo # Pke-r find ( Po-)c f c.P\n c (..1.4'-‘ --i'%"1"
The proposed project to be located and constructed as described This certification of exemption from requiring a CAMA permit is
above is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following expiration,
quirement pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be necessary
CAMA permit requirements does not alleviate the necessity of to continue this certification.
your obtaining any other State, Federal, or Local authorization.
SKETCH (SCALE: J,J - )
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Any person who proceeds with a development without the con- ` ' / 0 ,_ ,' ,',_L t`(
sent of a CAMA official under the mistaken assumption that the Applicant's signature
development is exempted,will be in violation of the CAMA if there ---
is a subsequent determination that a permit was required for the
development. IC IQ...,
C
f i I AMA ic 's signature
v , aOO
The applicant certifies by signing this exemption that (1)the ap- Issuing date
plicant has read and will abide by the conditions of this exemp-
tion,and(2)a written statement has been obtained from adjacent CTVe-r Q-A. a'8 2 UU j
landowners certifying that they have no objections to the Expiration date
proposed work.
Attachment: 15 North Carolina Administrative Code 7K.0203

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DATE: (-'ti-oL
I HERESY CERTIFY THAT THE ATTACHED
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LAND SHOWN ON THIS PLAT 13 WITHIN TN [ EIP a EXISTING IROH PIPE----WI 1USDIVISIDN REGULATION JURISDICTION Of HIP o NfW IRON PIPE M 0 CONCRETE MONUM(N
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DATE: 1--i4-QL-
I HERESY CERTIFY THAT THE ATTACHED
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PLA T YID UNDER AM11111V, fSV1i1ON.
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