20031639 Ver 1_Certification of Completion_20051005

` 10~~~ v~.,,~9QG
r
>_ ~
Q Y
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E., Director
Division of Water Quality
DWQ Project No.: ~~i'~ ~~-1 County: .~o,~ ~ ~ R o~1 ~'~~1 ~~~~ ~~
Applicant:
Project Name:
Date of Issuance of 401 Water Quality Certification: ~~t ~ 27 ~ 2~~
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification and Buffer Rules, and any
subsequent modifications, the applicant is required to return this certificate to the 401/Wetlands Unit, North Carolina
Division of Water Quality, 1621 1Vlail Service Center, Raleigh, NC, 27699-1621. This form may be returned to DWQ
by the applicant, the applicant's authorized agent, or the project engineer. It is not necessary to send certificates from
all of these.
Applicant's Certification
I, ~~n l ' ~ • , ~ 1 ~ ~J~• ,hereby state that; to the best of my abilities, due care and diligence
was used in the observation o the construction such that the construction was observed to be built within substantial
compliance and intent of the 401 Water Quality Certification and Buffer Rules; the approved plans and specifications,
and other supporting materials. _
Signature: ~'N~ -/q- %~'~t,~ Date: ©G~o~psY S~ ZQ1.$'
v-
Agent's Certification
1, ;hereby state that, to the' best of my abilities, due care and diligence
was used in the observation of the construction such that the construction was observed to be built within substantial
compliance and intent of the 401 Water Quality Certification and Buffer Rules, the approved plans and specifications,
and other supporting materials.
Signature: Date:
If this project was designed by a Certified Professional
~ .. as a duly registered Professional (i.e., ~ Engineer,
Landscape Architect, Surveyor, etc.) in the State of North Carolina, having been authorized to observe (periodically,
weekly, full time) the construction of the project, for the Permittee hereby state that, to the best of my abilities, due
care and diligence was used in the observation of the construction such that the construction was observed to be built
within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the approved plans
and specifications, and other supporting materials.
Signature:
Registration No.
N. C. Division of Water GZuality, 401 Wetlands Certification Unit;
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
[phone] (phone), 919-733-6893 (fax), (http://h2o.enr.state.nc.us/ncwetlands
Date