General Permits (567)

O
CERTIFICATION OF EXEIV
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina, L-M '
Department of Environment, Health, and Natural Resources and the
in an area of environmental concern pursuant to 15 NCAC Subchap-
Applicant Name. —
Address 'rlL..)
City
Project Location (County, State Road, Water Body, etc.)
VA.
! '� ij\
Phone Number t1�� •,tea tied.\
Type and Dimensions of Project C_ C, X I-' U t�, .
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 fo.r_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: NUNE,
)
Lk u
I �
i
L
V rtr.
Wily rcrovi ...w L.., ............ ...... .. .......,..�......,... ......__. ...- --..
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.
'Applicant's snature
)f�
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203