General Permits (309)

Applicant Nan
Address
City
CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT ,, f.. `.
r
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
in an area fof� ironmen al concern pursuant to 15 NCAC Subchapter 7K AW,
Phone Number �'0%,10
n (County, State Road,
, A:/am
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.
State IKl6
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
r
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.
Applicant's signature
t"/Yv" lby
CAMA Official's si t • re
;� /,VA,
Issuing ate /'I�
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

GENERAL PERMIT APPLICATION WORKATION
APPLICANT'S NAME:
R 4kNG ADDRESS:
(PERKANE Tr) `horn/
i
Last
TATE A91, Cat ZIP
TELEPHONE: WORK ( ) (p . HOME ( )
CONTRACTOR'S NAME: , TELEPHONE NUMBER
PROJECT LOCATION: N.C. Hwy. SR Road/Street Name
Waterway Name County -�
Town J��4AX4:)toll — 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
�'SFOUSE/BOAT LIFT: Length
Number of Piles
Number of Mooring piles
Width
Water Depth
BULKHEAD: #1 Total length
verage distance waterward MHW `moo;
Maximum distance waterward MHW
#2 Total length i
Average distance waterward MHW
Maximum distance waterward MHW
RIPRAP: Total length Base width from MHW
EXCAVATION: [MAINTENANCE 'ONLY']
Length Width 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
Dragline
OTHER STRUCTURES:
_ Mud
Backhoe Hydraulic
i
i

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
.� 's property located at
(Namd o Property Owner) 30c� a
(Lot, Block, Road, etc.)
t
on in GL��c N.C.
�(Wcft erbody) (Townand/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)
i
i
4
Signature
Print or Type Name
c9� �2_ 2
Telephone Number

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER)
I e eb rti / that I �w�n rAperty adjacent to
- 's property
located at % / 1Z.r' L-01p � , on
( Lot, qMd6k, Road, etc.) /�
in et"J_ L'�t-'T
( N.C.
(Witer 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. I understand that a pier must be set back a minimum
distance of fifteen feet (15') from my area of riparian access
unless waived by me.
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
)EVELOPMENT )
—sa� �M s
Signature
Name
-726- 6056
Phone Number