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HomeMy WebLinkAbout20060377 Ver 1_Complete File_20060308?f / y.. sTAiio ? N ? OwM STATE OF NORTH CAROLINA ti DEPARTMENT OF TRANSPORTATION `y MICHAEL F. EASLEY LYNDO TIPPETT GOVERNOR SECRETARY March 3, 2006 U.S. Army Corps of Engineers Raleigh Regulatory Field Office ?()60377 6508 Falls of the Neuse Road, Suite 120 Raleigh, NC 27609 Attention: Mr. Eric Alsmeyer, NCDOT Coordinator Subject: Proposed maintenance improvements to a structure conveying Pounder Branch on SR 1533 (Vicksboro Road) in Vance County. WBS element 513.2091 It, STAT 10# 9800765. The North Carolina Department of Transportation (NCDOT) proposes to replace a pipe conveying Pounder Creek on SR 1533 (Vicksboro Road) in Vance County (Figures 1 -3). Impacts to Waters of the United States The project crosses a perennial stream, Pounder Branch, [NCDENR-DWQ Index No. 28- 78-1-2, Best Usage Classification C NSW; HUC 03020101] (Figure 3) in the Tar- Pamlico River Basin. The existing structure that conveys the creek is a 72-inch corrugated metal pipe arch that is 60 feet long with a headwall at the inlet (see Photographs 1-3). This existing structure is rusted and undersized. The NCDOT proposes to replace the existing structure with a 90-inch corrugated metal pipe arch that is 60 feet long. Ten feet of rip rap will be placed along the creek banks both upstream and downstream of the structure. During the construction of the project, the NCDOT proposes to temporarily dewater the work zone for approximately 2 weeks. This will involve the temporary placement of sheet piling at the construction limits. To maintain water flow during construction, water upstream of the sheet piling will be temporarily pumped out by a hose and conveyed downstream of the construction activity where it will be allowed to filter through vegetation before flowing into the stream. The effluent from the work area will be pumped into a prefabricated silt bag allowing water to slowly filter out of the bag in a dispersed matter and the sediment to be captured in the bag. Once the stream has been dewatered, the pipe will be replaced. The sheet piling will be removed after construction. Division 5, 2612 N. Duke Street, Durham, NC 27704 Phone: (919) 560-6081 Fax: (919) 560-3371 A LIN r f /+ y / li i,? w?'? ? ?:}- •?T? >,•-,? ,,^ :lower' , 52 1 sc, "e"rr \ ('' , ? ?; ' •?'` 111 _'.?? ? °?? ???(} J r / ? i*- ?i4 r J ?. ?>'(•? -.\ 1 ,,• ? i .., < I J ttr - 't. i \ _ "; r .• J y 1?- .: ,' t ++ G ?, 1. Nil I it ,i; lA cb' roA1?0$U , 43, rui ... ? .,,, •; OY?m. :,,^• ? ,, r7 T J' r J ?l lt?? \ r ??? \, 4'^. /i?'. ?/r'? ? , r .If i ?q'?•;, ,1,\ff , ?J? `,_,???,? , 'l: ?..,? \ ; ?,?.? ?? ,-? (. ; - - ` .?'? I -? ?, 1 SITE l ;7 '? ?'1';• \ 1 1 y 4n, / y'/ .., + +. a ?_... 'r?fM ' / t 1 w ? t: .• b r? ?Y •f'' ?; ?? 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F e APB 7 i i a ? `1 ', p n} i DaB2 e:?r,? ?> P v '.'S,s?` .,r iu +:'E. fur ?(;OQ >r ? ?/ ,? WeD ts19 # Y . y, LoB tdP,6 i 1. ? < d ;1t 4 ' CeD2 y. i y "' Lob I ,? '?':.? ,-•?3 •.,?`gs`? LoD •i LO ? ? '' sEx .?r'' ?. LoD m ? Y A' r y?y ?) I .S' .r t • 'A? ?', r r.f_. 1 ?.R ! {..IF'. fd'" v. ... to[Y? ? WeD 4P8 ,?ylw• LoE APB - ,^ of h ? .,?.. .. •Lo8 ?. a r. o O ?Lo,D ' dqd 1 ?y t d APB, m ;' rrr APB ;. ? ? 'aB2 LOO 2139000 FEET N Project Study Area SR 1533 Vicksboro Road Vance County USDA-SCS (1977) Figure 2 1:24,000 >; T a C C) ? ? U a c _ C r N C U) O a? O .. L CL L o. c Q c 4- 3 4- 0 O N C L- O O E 4- N U W O cl? -0 N U) Y U o• ? c o ? i 'f- X O O Q0 L.L W W \o 0 M N N 0 „C O a? 0 N O ? O en u en > w r u c a + c O •- O L C N U + D 4- 3 O N 4- C N O E N U CL dscnO336(70062544b1Pe9) Photograph 1. View Upstream. dscriOMS (70042544b Jpeg) Photograph 2. View of Outlet. SR 1533 (Vicksboro Road) i dscnO334(70Ox525x24bJpeg) i <f, Photograph 3. View of Downstream. Permanent impacts at the site associated with the replacement of the structure involve a total of 20 feet of rip rap placed along the streambank to protect the structure. Temporary concurent impacts will include the dewatering of 20 feet of stream. Riparian Buffer Construction at this site involves a road crossing of a stream that is subject to the Tar-Pamlico River Riparian Buffer Rules. Pounder Branch at Site 1 is depicted on the most recent version of the Vicksboro (USGS 1970) topographic quadrangle (Figure 1) as well as the Soil Survey of Vance County (USDA-SCS, 1977) (Figure 2). Construction impacts at this site total 1,387 ftz in Zone 1 and 0 ftz in Zone 2 (totaling 20 linear feet of riparian buffer impacts). Please note that impacts associated with installation of the sheet piling and special stilling basin (silt bag) are included as part of these totals. Based on the impacts to the riparian buffer at this site, this crossing is EXEMPT. Waters of the U.S. Mitigation Avoidance: All wetlands and surface waters not affected by the project will be protected from unnecessary encroachment. No staging of construction equipment or storage of construction supplies will be allowed in wetlands or near surface waters. Minimization: The side slopes have been steepened to the extent possible at jurisdictional sites. Strict enforcement of sedimentation and erosion control Best Management Practices for the protection of wetlands and surface waters will be enforced during project construction. Continued coordination will occur with maintenance forces and the Environmental Officer during construction to minimize impacts to these sites. Compensatory Mitigation: All compensatory mitigation requirements will be left to the discretion of the regulatory review agencies. Protected Species Plants and animals with federal classifications of Endangered, Threatened, Proposed Endangered and Proposed Threatened are protected under provisions of Section 7 and Section 9 of the Endangered Species Act. As of March 03, 2006, the dwarf wedgemussel (Alasmidonta heterodon) and bald eagle (Haliaeetus leucocephalus) are listed as federally protected species in Vance County. This project is not adjacent to nor is it surrounded by open water suitable of supporting foraging habitat for the bald eagle. A mussel survey was conducted at this crossing by biologists with Alderman Environmental Services, Inc. on February 25, 2006 with a finding of no effect for federally protected species. Additionally, a review of the Natural Heritage Program database (last updated January 2006) revealed no occurrences of protected species within the project area. Therefore, based on lack of suitable habitat observed during the site visit and the NHP database review, biological conclusions of No Effect have been rendered for each species. Summary The NCDOT proposes to replace the existing structure with larger sized pipe. Permanent impacts at the site associated with the replacement of the structure involve a total of 20 feet of rip rap placed along the streambank to protect the structure. The work zone will be dewatered for approximately 2 weeks. Temporary concurrent impacts to the stream from this activity will result in the dewatering of 20 linear feet of stream. The sheet piling will be removed after construction. Riparian buffer im acts at Site 1 associated with this maintenance activity total 1,387 ft2 in Zone 1 and 0 ft in Zone 2 (totaling 20 linear feet of riparian buffer impacts). Based on the impacts to the riparian buffer at this site, this crossing is EXEMPT. Application is hereby made for a Department of the Army Section 404 Nationwide Permit (NWP) 3, NWP 33, and NCDENR-DWQ Section 401 Water Quality Certification (WQC) No. 3494, WQC No. 3366, and riparian buffer authorization for above-described activities. An automated payment procedure has been implemented between the NCDOT and NCDENR-DWQ. This procedure will enable the Division to apply for the 401 WQC without submitting a check for this permit application. This procedure will provide payment to the NCDENR-DWQ by charging the permit application fee of $200.00 directly to the appropriate NCDOT WBS element 513.209111, STAT IO# 9800765. A pre-construction notification is attached with this request. If you have any questions or need additional information, please contact Mr. Chris Murray at (919)560-6851. Since?ance, Jon G .E. Division Engineer cc: Nicole Thomson, NCDWQ Dallie Bagwell, NCDOT Earl Bell, NCDOT Katie Simmons, NCDOT Office Use Only: Fonn Version March 05 20060 377 USACE Action ID No. DWQ No. (If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A".) Processing 1. Check all of the approval(s) requested for this project: ® Section 404 Permit ® Riparian or Watershed Buffer Rules ? Section 10 Permit ? Isolated Wetland Permit from DWQ ® 401 Water Quality Certification ? Express 401 Water Quality Certification 2. Nationwide, Regional or General Permit Number(s) Requested: NWP 3 and NWP 33 3. If this notification is solely a courtesy copy because written approval for the 401 Certification is not required, check here: 4. If payment into the North Carolina Ecosystem Enhancement Program (NCEEP) is proposed for mitigation of impacts, attach the acceptance letter from NCEEP, complete section VIII, and check here: ? 5. If your project is located in any of North Carolina's twenty coastal counties (listed on page 4), and the project is within a North Carolina Division of Coastal Management Area of Environmental Concern (see the top of page 2 for further details), check here: ? II. Applicant Information Owner/Applicant Information Nanne: NCDOT Division 5 Jon G. Nance Mailing Address: 2612 N. Duke St. Durham NC 27704 Telephone Number: (919) 560-6851 Fax Number: (919) 560-3371 E-mail Address: JNance a dot state nc us 2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter must be attached if the Agent has signatory authority for the owner/applicant.) Name: Company Affilial Mailing Address: Telephone Number: Fax Number: E-mail Address: Page 1 of 8 III. Project Information Attach a vicinity map clearly showing the location of the property with respect to local landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property boundaries and development plans in relation to surrounding properties. Both the vicinity map and site plan must include a scale and north arrow. The specific footprints of all buildings, impervious surfaces, or other facilities must be included. If possible, the maps and plans should include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion, so long as the property is clearly defined. For administrative and distribution purposes, the USACE requires information to be submitted on sheets no larger than 11 by 17-inch format; however, DWQ may accept paperwork of any size. DWQ prefers full-size construction drawings rather than a sequential sheet version of the full-size plans. If full-size plans are reduced to a small scale such that the final version is illegible, the applicant will be informed that the project has been placed on hold until decipherable maps are provided. 1. Name of project: Proposed replacement of a structure convening Pounder Branch on SR 1533 (Vicksboro Road) in Vance County. 2. T.I.P. Project Number or State Project Number (NCDOT Only): N/A 3. Property Identification Number (Tax PIN): N/A 4. Location County: Vance Nearest Town: Henderson Subdivision name (include phase/lot number): N/A Directions to site (include road numbers/names, landmarks, etc.): While traveling north along US I BYP on the southeast side of Henderson take the Bear Pond Road Exit. Travel east on Bear Pond Rd (aka Linbanks Rd) for approximately 2.0 miles to intersection with Gillburg Road. Make a left onto Gillburg Road and travel north for 1.0 mile, cross through intersection with Hwy 39, then continue for another 2.8 miles. Make a right onto SR 1533 (Vicksboro Road) and travel to project site. 5. Site coordinates (For linear projects, such as a road or utility line, attach a sheet that separately lists the coordinates for each crossing of a distinct waterbody.) Decimal Degrees (6 digits minimum): 36.3203 ON 78.3507 "W 6. Property size (acres): 0.20 acre 7. Name of nearest receiving body of water: Pounder Branch 8. River Basin: Tar-Pamlico (Note - this must be one of North Carolina's seventeen designated major river basins. The River Basin map is available at http•//b2o.enr.state.nc.us/admits/maps/.) Page 2 of 8 9. Describe the existing conditions on the site and general land use in the vicinity of the project at the time of this application: Site is surrounded by wooded areas and agricultural land. 10. Describe the overall project in detail, including the type of equipment to be used: The NCDOT will replace the existing structure at Site 1. The NCDOT will also dewater the work zone during construction. Equipment may include excavator, backhoe, bulldozer, grader, and crane. 11. Explain the purpose of the proposed work: The existing structure is undersized. IV. Prior Project History If jurisdictional determinations and/or permits have been requested and/or obtained for this project (including all prior phases of the same subdivision) in the past, please explain. Include the USACE Action ID Number, DWQ Project Number, application date, and date permits and certifications were issued or withdrawn. Provide photocopies of previously issued permits, certifications or other useful information. Describe previously approved wetland, stream and buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project, list and describe permits issued for prior segments of the same T.I.P. project, along with construction schedules. N/A V. Future Project Plans Are any future pen-nit requests anticipated for this project? If so, describe the anticipated work, and provide justification for the exclusion of this work from the current application. N/A VI. Proposed Impacts to Waters of the United States/Waters of the State It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to wetlands, open water, and stream channels associated with the project. Each impact must be listed separately in the tables below (e.g., culvert installation should be listed separately from riprap dissipater pads). Be sure to indicate if an impact is temporary. All proposed impacts, permanent and temporary, must be listed, and must be labeled and clearly identifiable on an accompanying site plan. All wetlands and waters, and all streams (intermittent and perennial) should be shown on a delineation map, whether or not impacts are proposed to these systems. Wetland and stream evaluation and delineation forms should be included as appropriate. Photographs may be included at the applicant's discretion. If this proposed impact is strictly for wetland or stream mitigation, list and describe the impact in Section VIII below. If additional space is needed for listing or description, please attach a separate sheet. 1. Provide a written description of the proposed impacts: The NCDOT will replace the existing structure at Site 1 with a larger pipe of the same leng1h The NCDOT will also dewater the work zone during construction Page 3 of 8 r r 2. Individually list wetland impacts. Types of impacts include, but are not limited to mechanized clearing, grading, fill, excavation, flooding, ditching/drainage, etc. For dams, cennrntely lict imnnrtc fine to hnth structure and floodinu. Wetland Impact Site Number (indicate on map) Type of Impact Type of Wetland (e.g., forested, marsh, herbaceous, bog, etc.) Located within 100-year Floodplain es/no) Distance to Nearest Stream (linear feet) Area of Impact (acres) N/A Total Wetland Impact (acres) N/A 3. List the total acreage (estimated) of all existing wetlands on the property: N/A 4. Individually list all intermittent and perennial stream impacts. Be sure to identify temporary impacts. Stream impacts include, but are not limited to placement of fill or culverts, darn construction, flooding, relocation, stabilization activities (e.g., cement walls, rip-rap, crib walls, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is proposed, plans and profiles showing the linear footprint for both the original and relocated streams mnof l,P ;nrliirlnrl Tn rnlrnlnfe nnrenur mnltinly length X width. then divide by 43,560. Stream Impact Perennial or Average Impact Area of Number Stream Name Type of Impact Intermittent' Stream Width Length Impact (indicate on ma) . Before Impact linear feet acres Site 1 Pounder Branch Fill (piped length) Perennial 15 0 0 Rip rap armoring 20 0.007 along stream bank Temporary 20 0.007 dewatering concurrent concurrent Total Stream Impact (by length and acreage) 20 0.007 5. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic Ocean and any other water of the U.S.). Open water impacts include, but are not limited to f';I1 nv -nt;nn rlrorlcr;nn flnndiner rlrninavr hlllkhends- etc. Open Water Impact Site Number Name Waterbody Type of Impact Type of Waterbody (lake, pond, estuary, sound, bay, Area of Impact (indicate on ma) applicable) e) (if ap ocean, etc.) (acres) N/A Total Open Water Impact (acres) N/A 6 List the cumulative impact to all Waters of the U.S. resulting from the project. Stream Impact acres): 0.007 Wetland Impact (acres): NONE Open Water Impact (acres): NONE Total Impact to Waters of the U.S. (acres) 0.007 Total Stream Impact (linear feet): 20 Page 4 of 8 7. Isolated Waters Do any isolated waters exist on the property? ? Yes ®No Describe all impacts to isolated waters, and include the type of water (wetland or stream) and the size of the proposed impact (acres or linear feet). Please note that this section only applies to waters that have specifically been determined to be isolated by the USAGE. 8. Pond Creation If construction of a pond is proposed, associated wetland and stream impacts should be included above in the wetland and stream impact sections. Also, the proposed pond should be described here and illustrated on any maps included with this application. Pond to be created in (check all that apply): ? uplands ? stream ? wetlands Describe the method of construction (e.g., dam/embankment, excavation, installation of draw-down valve or spillway, etc.): N/A Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond, local stormwater requirement, etc.): N/A Current land use in the vicinity of the pond: N/A Size of watershed draining to pond: N/A Expected pond surface area: N/A VII. Impact Justification (Avoidance and Minimization) Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide information related to site constraints such as topography, building ordinances, accessibility, and financial viability of the project. The applicant may attach drawings of alternative, lower-impact site layouts, and explain why these design options were not feasible. Also discuss how impacts were minimized once the desired site plan was developed. If applicable, discuss construction techniques to be followed during construction to reduce impacts. All wetlands and surface waters not affected by construction will be protected from unnecessary encroachment during construction Strict enforcement of Best Management Practices for the protection of wetlands and surface waters will be enforced during construction Only the smallest amount of fill necessary to complete the project will be placed in waters of the United States. VIII. Mitigation DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC Division of Water Quality for projects involving greater than or equal to one acre of impacts to freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial streams. USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide Permits, published in the Federal Register on January 15, 2002, mitigation will be required when necessary to ensure that adverse effects to the aquatic environment are minimal. Factors including size and type of proposed impact and function and relative value of the impacted aquatic resource will be considered in determining acceptability of appropriate and practicable Page 5 of 8 mitigation as proposed. Examples of mitigation that may be appropriate and practicable include, but are not limited to: reducing the size of the project; establishing and maintaining wetland and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of aquatic resource functions and values by creating, restoring, enhancing, or preserving similar functions and values, preferable in the same watershed. If mitigation is required for this project, a copy of the mitigation plan must be attached in order for USACE or DWQ to consider the application complete for processing. Any application lacking a required mitigation plan or NCEEP concurrence shall be placed on hold as incomplete. An applicant may also choose to review the current guidelines for stream restoration in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at http://h2o.enr.state.nc.us/iicwettands/strmgide.htinl. 1. Provide a brief description of the proposed mitigation plan. The description should provide as much information as possible, including, but not limited to: site location (attach directions and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet) of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view, preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a description of the current site conditions and proposed method of construction. Please attach a separate sheet if more space is needed. All compensatory mitigation requirements will be left to the discretion of the regulatory review agencies. 2. Mitigation may also be made by payment into the North Carolina Ecosystem Enhancement Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at (919) 715-0476 to determine availability, and written approval from the NCEEP indicating that they are will to accept payment for the mitigation must be attached to this form. For additional information regarding the application process for the NCEEP, check the NCEEP website at http://h2o.enr.state.nc.us/wrp/index.htm. If use of the NCEEP is proposed, please check the appropriate box on page five and provide the following information: Amount of stream mitigation requested (linear feet): Amount of buffer mitigation requested (square feet): N/A Amount of Riparian wetland mitigation requested (acres): N/A Amount of Non-riparian wetland mitigation requested (acres): N/A Amount of Coastal wetland mitigation requested (acres): N/A IX. Environmental Documentation (required by DWQ) 1. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land? Yes ® No ? 2. If yes, does the project require preparation of an environmental document pursuant to the requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)? Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA coordinator at (919) 733-5083 to review current thresholds for environmental documentation. Yes ? No Page 6 of 8 3. If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a copy of the NEPA or SEPA final approval letter. Yes ? No ? X. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ) It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to required state and local buffers associated with the project. The applicant must also provide justification for these impacts in Section VII above. All proposed impacts must be listed herein, and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ Regional Office may be included as appropriate. Photographs may also be included at the applicant's discretion. 1. Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233 (Neuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 02B .0243 (Catawba) 15A NCAC 2B .0250 (Randleman Rules and Water Supply Buffer Requirements), or other (please identify )? Yes ? No ? 2. If "yes", identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer mitigation is required calculate the required amount of mitigation by applying the buffer multipliers. Site 1 Zone* Impact (square feet) Multiplier Required Miti gation 1 1,387 3 (2 for Catawba) N/A 2 0 1.5 N/A Total 1,387 N/A * Zone I extends out 30 feet perpendicular from the top of the near bank of channel; Zone 2 extends an additional 20 feet from the edge of Zone 1. 3. If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation of Property, Riparian Buffer Restoration / Enhancement, or Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as identified within 15A NCAC 2B .0242 or .0244, or .0260. N/A XI. Stormwater (required by DWQ) Describe impervious acreage (existing and proposed) versus total acreage on the site. Discuss stormwater controls proposed in order to protect surface waters and wetlands downstream from the property. If percent impervious surface exceeds 20%, please provide calculations demonstrating total proposed impervious level. There is 0.04 acre existing impervious surface with the 0.2 acre project site No additional impervious surface is proposed with this maintenance pipe replacement' proiect Erosion and sediment control devices at this site are comprised of temporary silt fence and special stilling basin (silt bag) Page 7 of 8 XII. Sewage Disposal (required by DWQ) Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of wastewater generated from the proposed project, or available capacity of the subject facility. This project will not generate wastewater. XIII. Violations (required by DWQ) Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules? Yes ? No Is this an after-the-fact permit application? Yes ? No XIV. Cumulative Impacts (required by DWQ) Will this project (based on past and reasonably anticipated future impacts) result in additional development, which could impact nearby downstream water quality? Yes ? No If yes, please submit a qualitative or quantitative cumulative impact analysis in accordance with the most recent North Carolina Division of Water Quality policy posted on our website at http://h2o.etir.state.tic.ushlcwetlands. If no, please provide a short narrative description: XV. Other Circumstances (Optional): It is the applicant's responsibility to submit the application sufficiently in advance of desired construction dates to allow processing time for these permits. However, an applicant may choose to list constraints associated with construction or sequencing that may impose limits on work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and Threatened Species, accessibility problems, or other issues outside of the applicant's control). 41-1 3/3, Agnicant/Agent's Signature Date (Agent's ature is valid only if an authorization letter from the applicant is provided.) Page 8 of 8