HomeMy WebLinkAbout20021558 Ver 1_Application_20020927r
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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
March 17, 2006
Chatham County
•DWQ Project No. 20021558
SR 1131
APPROVAL of 401 Water Quality Certification
Mr. Timothy Johnson, P.E., Division Engineer
North Carolina Department of Transportation, Division 8
PO Box 1067
Aberdeen, North Carolina, 28315
Dear Mr. Johnson:
You have our approval, in accordance with the attached conditions and those listed below, to place
permanent fill material, 6ulverts, and piping in 28 linear feet of streams (28 linear feet total) for the
purpose of widening SR 1131 in Chatham County. The stream impacts are approved as presented in the
tables below.
Stream Impacts in the Yadkin-Pee Dee River Basin
Site Stream Type Stream Impact Type Impacts
Name Classification/ (Linear Feet)
Index No.
1 UT to Brush Intermittent Class C/17-23 Permanent 28
Creek
Total 28
The project shall be constructed in accordance with your application dated January 13, 2006 (received
January 20, 2006) and the additional information letter dated February 21, 2006 (received February 24,
2006). After reviewing your application, we have decided that this fill is covered by General Water
Quality Certification Number 3404. This certification corresponds to Nationwide Permit 14 issued by. the
Corps of Engineers. In addition, you should acquire any other federal, state or local permits before you
proceed with your project including (but not limited to) Sediment and Erosion Control, Non-Discharge
and Water Supply Watershed regulations. This approval will expire with the accompanying 404 permit,
unless otherwise specified in the Water Quality Certification.
This approval is valid solely for the purpose and design described in your application (unless modified
below). Should your project change, you must notify the DWQ and submit a new application. If the
property is sold, the new owner must be given a copy of this Certification and approval letter, and is
thereby responsible for complying with all the conditions. If total wetland fills for this project (now or in
the future) exceed one acre, or of total impacts to streams (now or in the future) exceed 150 linear feet,
compensatory mitigation may be required as described in 15A NCAC 2H.0506 (h) (6) and (7). For this
approval to remain valid, you must adhere to the conditions listed below and in the attached certification.
Nose Carolina
Transportation Permitting Unit N turQ1ilf
1650 Mail Service Center, Raleigh, North Carolina 27699-1650
2321 Crabtree Boulevard, Suite 250, Raleigh, North Carolina 27604
Phone: 919-733-17861 FAX 919-733-6893 / Internet: http://h2o.enr.state.nc.us/ncwetlands
An Eaual Onnortunity/Affirmative Action Emnlover - 50% Recvcled/10% Post Consumer Paoer
Mr. Johnson
March 17, 2006
1. Upon completion of the project, the NCDOT Division Engineer shall complete and return the
enclosed "Certification of Completion Form" to notify DWQ when all work included in the 401
Certification has been completed.
2. All work in or adjacent to stream waters shall be conducted in a dry work area. Approved BMP
measures from the most current version of NCDOT Construction and Maintenance Activities
manual such as sandbags, rock berms, cofferdams and other diversion structures shall be used to
prevent excavation in flowing water.
3. Erosion and sediment control practices must be in full compliance with all specifications
governing the proper design, installation and operation and maintenance of such Best
Management Practices in order to protect surface waters standards:
a. The erosion and sediment control measures for the project must be designed, installed,
operated, and maintained in accordance with the most recent version of the North
Carolina Sediment and Erosion Control Planning and Design Manual.
b. The design, installation, operation, and maintenance of the sediment and erosion control
measures,must be such that they equal, or exceed, the requirements specified in the most
recent version of the North Carolina Sediment and Erosion Control Manual. The devices
shall be maintained on all construction sites, borrow sites, and waste pile (spoil) projects,
including contractor-owned or leased borrow pits associated with the project.
c. For borrow pit sites, the erosion and sediment control measures must be designed,
installed, operated, and maintained in accordance with the most recent version of the
North Carolina Surface Mining Manual.
d. The reclamation measures and implementation must comply with the reclamation in
accordance with the requirements of the Sedimentation Pollution Control Act.
4. Placement of culverts and other structures in waters, streams, and wetlands shall be placed below
the elevation of the streambed by one foot for all culverts with a diameter greater than 48 inches,
and 20 percent of the culvert diameter for culverts having a diameter less than 48 inches, to allow
low flow passage of water and aquatic life. Design and placement of culverts and other structures
including temporary erosion control measures shall not be conducted in a manner that may result
in dis-equilibrium of wetlands or streambeds or banks, adjacent to or upstream and down stream
of the above structures. The applicant is required to provide evidence that the equilibrium is being
maintained if requested in writing by DWQ. If this condition is unable to be met due to bedrock
or other limiting features encountered during construction, please contact the NC DWQ for
guidance on how to proceed and to determine whether or not a permit modification will be
required.
5. If concrete is used during construction, a dry work area should be maintained to prevent direct
contact between curing concrete and stream water. Water that inadvertently contacts uncured
concrete should not be discharged to surface waters due to the potential for elevated pH and
possible aquatic life and fish kills.
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6. During the construction of the project, no staging of equipment of any kind is permitted in waters
of the U.S., or protected riparian buffers.
Mr. Johnson
March 17, 2006
7. The dimension, pattern and profile of the stream above and below the crossing should not be
modified. Disturbed floodplains and streams should be restored to natural geomorphic
conditions.
8. Any riprap used must not interfere with thalweg performance and aquatic life passage during low
flow conditions.
9. Heavy equipment must be operated from the banks rather than in the stream channel in order to
minimize sedimentation and reduce the likelihood of introducing other pollutants into the stream.
10. All mechanized equipment operated near surface waters must be regularly inspected and
maintained to prevent contamination of stream waters from fuels, lubricants, hydraulic fluids, or
other toxic materials.
11. No rock, sand or other materials shall be dredged from the stream channel except where
authorized by this certification.
12. All work shall be. performed during low or normal flow conditions.
13. Discharging hydroseed mixtures and washing out hydroseeders and other equipment in or
adjacent to surface waters is prohibited.
14. NCDOT and its authorized agents shall conduct its activities in a manner consistent with State
water quality standards (including any requirements resulting from compliance with §303(d) of
the Clean Water Act) and any other appropriate requirements of State and Federal law. If DWQ
determines that such standards or laws are not being met (including the failure to sustain a
designated or achieved use) or that State or federal law is being violated, or that further
conditions are necessary to assure compliance, DWQ may reevaluate and modify this
certification.
15. A copy of this Water Quality Certification shall be posted on the construction site at all times. In
addition, the Water Quality Certification and all subsequent modifications, if any, shall be
maintained with the Division Engineer and the on-site project manager.
16. The outside buffer, wetland or water boundary located within the construction corridor approved
by this authorization shall be clearly marked by highly visible fencing prior to any land disturbing
activities. Impacts to areas within the fencing are prohibited unless otherwise authorized by this
certification.
17. There shall be no excavation from, or waste disposal into, jurisdictional wetlands or waters
associated with this permit without appropriate modification. Should waste or borrow sites be
located in wetlands or streams, compensatory mitigation will be required since that is a direct
impact from road construction activities.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing.
You must act within 60 days of the date that you receive this letter. To ask for a hearing, send a written
petition that conforms to Chapter 150B of the North Carolina General Statutes to the Office of
Administrative Hearings, 6714 MSC, Raleigh, N.C. 27699-6714. This certification and its conditions are
final and binding unless you ask for a hearing.
Mr. Johnson
March 17, 2006
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water
Act. If you have any questions, please contact Brian Wrenn at 919-733-5715 or John Hennessy at 919-
733-5694.
Sincerely,
J?L- 4 n
Alan W. Klimek, P.E.
Attachment
cc: Richard Spencer, Amy Corps of Engineers Wilmington Regulatory Field Office
Ken Averitte, DWQ Faeyetteville Regional Office
Travis Wilson, NC WRC
Gary Jordan, US FWS
Chris Militscher, US EPA
File Copy
Central Files
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STATE OF NORTH CAROLINA
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DEPARTMENT OF TRANSPORTATION ?yycy
MICHAEL, F. EAsLEY DIVISION OF HIGHWAYS LYNDO TIPPETT
GOVERNOR SECRETARY
February 21, 2006
Memorandum To: John Hennessy
NCDWQ 401 wetlands Unit
From: Art C. King, DEO a<
NCDOT Highway Div. 8
Subject: 401 Water Quality Certification for SR-1131 Chatham County
DWQ # 20021558
Contained in this package are the modifications you requested in your February 2, 2006 letter for
the re-certification of DWQ # 20021558 on SR-1131 in Chatham County. Included is a modified
plan drawing that shows the location of the existing pipe, and our generic design for a temporary
diversion. Because this pipe is located within an intermittent stream channel, it will be possible for
construction to be done under dry conditions. Any construction at this location will be preformed
under the specifications listed in current version of the NCDOT Best management Practices
Manual for Construction and Maintenance Activities. A diversion will only be installed if
conditions require it. According to USACOE the use of movable devices (concrete barriers or
sheet metal plates) for temporary diversion of stream channels are not considered as fill materials
under sec. 404 of the Clean Water Act. The design we have submitted utilizes these devices and
does not constitute an increase in impacts to the waters of the United States.
To our knowledge there is no work planned to the ditch line or to any other erosion control or,
storm water control devices at this crossing. If any storm water devices are needed for this project
they will be appropriate to the site and installed in accordance with the NCDOT BMP Manual.
We do not anticipate any discharge of storm water from this project that would adversely effect
water quality.
Thank you for your assistance in this matter. If you have any questions or require any additional
information please contact me.
P.O. BOX 1067, ABERDEEN NORTH CAROLINA 28315
PHONE (910) 944-2344 FAX (910) 944-5623
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CONCRETE BARRIER OR
STEEL SHEET PILING
NOTES.
L) LVSTALL TEMPORARY BERMS, DIVERT STREAM
FLOW BY PUMPING WATER AROUND
WORK AREA.
Z) PUMP CONTAINED AREA TO SILT BAG
AND REMOVE EXISTING PIPE & HEADWALLS.
3.) INSTALL PIPE AAID BACIUILL
4.) REMOVE TEMPORARY DIVERSION DEVICES
ENERGY DISSIPATER
NOT TO SCALE
\-CONCRETE BARRIER OR
STEEL SHEET PILING
VIOUS FABRIC
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TEMPORARY DIVERSION DESIGN
ok William G. Ross Jr., Secretary
`O QG North Carolina Department of Environment and Natural Resources
Uj ram„ Alan W. Klimek, P.E. Director
y Division of Water Quality
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February 2, 2006
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
Tim Johnson, PE, Division Engineer
Division 8
NC Department of Transportation
PO Box 1067
Aberdeen, NC 28315
Re: Water Quality Certification for Proposed Improvements to SR 1131 in Chatham County, DWQ No.
20021558
Dear Mr. Johnson:
The Division of Water Quality has reviewed your submittal for a 401 Water Quality Certification for the
aforementioned project. Review of your application revealed it lacking necessary information required
for making an informed permit decision. The permit application was deficient in the following areas:
The drawings provided in your application do not show the existing pipe location at the road
crossing of the UT to Rocky River. Please provide drawings that show the existing pipe
locations, orientations, and dimensions.
It is unclear why there is no stream diversion drawing for the pipe replacement. All pipe
replacements shall be done in a dry work area. Please provide a diversion plan or provide an
explanation for how a dry work area will be maintained during the pipe replacement. If a
diversion is to be used, the temporary impacts for the diversion should be listed in the Stream
Impacts table in the PCN.
Therefore, pursuant to 15A NCAC 2H .0507(a)(5), we will have to place the permit application on hold
until we are supplied the necessary information. Furthermore, until the information is received by the NC
Division of Water Quality, we request (by copy of this letter) that the US Army Corps of Engineers place
the permit application on hold.
Hopefully, we can work together to expedite the processing of your permit application. If you have any
questions or require additional information, please contact Brian Wrenn at 919-733-5715.
Sincerely,
?G
;Alan . Klimek, P.E.
Director
Nose Carolina
Transportation Permitting Unit ° "'turQl?Zf
1650 Mail Service Center, Raleigh, North Carolina 27699.1650
2321 Crabtree Boulevard, Suite 250, Raleigh, North Carolina 27604
Phone: 919-733-1786 / FAX 919-733-6893 / Internet: http://h2o.enr.state.nc.us/ncwetlands
An Equal Opportunity/Affirmative Action Employer - 50% Recycled/10% Post Consumer Paper
February 2, 2006
Page 2
cc: Richard Spencer, US Army Corps of Engineers Wilmington Field Office
Travis Wilson, NC WRC
Gary Jordan, US FWS
Chris Militscher, US EPA
File Copy
?d Nra??
STATE OF NORTH CAROLINA
MICHAEL F. EASLEY
GOVERNOR
DEPARTMENT OF TRANSPORTATION
DIVISION OF HIGHWAYS
January 18, 2006
Memorandum To:
From:
Subject:
Rob Ridings
NCDWQ 401 Wetlands Unit
Art C. King, DE04e
NCDOT Highway Div. 8
401 Water quality Re-certifications
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LYNDO TIPPETT
SECRETARY
c? 2 / Ss8
Included are the applications for renewal of the 401 Water Quality Certifications for the projects
listed below. I am submitting two copies of each application as per your instructions. Please use
the corresponding WBS elements (project numbers) to obtain the renewals fees.
SR 2832 Randolph 8C.076022
SR 2316 Chatham 8C.019034
SR 1131 Chatham 8C.019074
SR 1367 Chatham 8C.019068
SR 1550 Chatham 8C.019075
SR 1134 Montgomery 8C.062005
If you require additional information please contact me.
Cy'. NO.
pp?
P.O. BOX 1067, ABERDEEN NORTH CAROLINA 28315
PHONE (910) 9442344 FAX (910) 944-5623
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Office Use Only: Form Version October 2001
USACE Action ID No. DWQ No. , 0 2 `/53-Q9 ,
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
1. Processing
1. Check all of the approval(s) requested for this project:
® Section 404 Permit
? Section 10 Permit
® 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: NWP 14
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 Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation),. check here: ?
II. Applicant Information
1. Owner/Applicant Information
Name: Tim Johnson, PE Division Engineer
NCDOT Highway Division 8
Mailing Address: PO Box 1067
Aberdeen, NC 28315
Telephone Number: (910)-944-2344 Fax Number: (910)-944-5623
E-mail Address:
2. Agent 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: Benny F. Sloan
Company Affiliation: N.C. Department of Transportation
Mailing Address: 1404 East Raleigh St.
Siler City, N.C. 27344
Telephone Number: (919)-742-3431 Fax Number: (919)-742-3986
E-mail Address: bfsloan@dot.state.nc.us
JAN G (i 7006
+ Page 5 of 12
I L11 LJ DENT; - WATER QUALITY
WETLANDS AND SToRMWATER BRANCH
i
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.
L Name of project: SR 1131 (Jim Page Rd)
2. T.I.P. Project Number or State Project Number (NCDOT Only): -G-223" IC • O I q D7z/
3. Property Identification Number (Tax PIN):
4. Location
County: Chatham Nearest Town: Siler City
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.): East on US 64, right on SR 1107
Travel 1.8 miles, left on SR 1100, travel 3.3 miles to SR 1130 and SR 1131 is on right.
5. Site coordinates, if available (UTM or Lat/Long): N35°40' 12" W79°30'40"
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this application:
Existing secondary road
7. Property size (acres
8. Nearest body of water (stream/river/sound/ocean/lake): Brush Creek
9. River Basin: Cape Fear
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
-6-
10. Describe the purpose of the proposed work: Grade and pave SR 1131 in Chatham County
11. List the type of equipment to be used to construct the project: Motorgrader, trackhoe,
bulldozer, scraper, etc.
12. Describe the land use in the vicinity of this project: Residential/agricultural
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.
V. Future Project Plans
Are any future permit 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. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must 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.
-7-
1. Wetland Impacts
Wetland Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres Located within
100-year Floodplain**
es/no Distance to
Nearest Stream
linear feet
Type of Wetland***
None
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, till,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http:/hvwrNv.fema.aov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stream Impacts, including all intermittent and perennial streams
Stream Impact
Site Number
indicate on ma
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Im act Perennial or
Intermittent?
leasespecify)
1 Perm 28' Brush Creek 21-3' I
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, 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 must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
wltitiv.usgs.rov. Several internet sites also allow direct download and printing of USGS maps (e.g., NvN,,w.topozone.com,
N«vlv.mapguest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: Site 1-28'
Page 8 of 12
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S.
Open Water Impact
Site Number
indicate on ma)
Type of Impact* Area of
Impact
(acres) Name of Waterbody
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)
None
# List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. 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.):
Size of watershed draining to pond: Expected pond surface area:
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.
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.
-9-
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, 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
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 NCWRP 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/ncwetlands/strm,izide.html.
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.
N/A
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at http://h2o.enr.state.ne.ushN-rp/index.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
-10-
IX.
Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes N No ?
X.
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 N
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 ?
Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
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.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 213 .0259 (Tar-Pamlico), 15A NCAC 213 .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No N If you answered "yes", provide the following information:
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.
Zone* (sqImpact uare feet) Multiplier Required Mitigation
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
-11-
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or .0260.
XI. Stormwater (DWQ Only)
Describe impervious acreage (both 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.
Neither the current impervious cover nor the new proposed impervious cover (gravel road bed or
asphalt pavement) will exceed 30% of the total site area. Erosion control devices appropriate to
the site will be utilized on this project which may include silt fences, check dams and storm
water retaining basins
XII. Sewage Disposal (DWQ Only)
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.
XHL Violations (DWQ Only)
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. 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).
l3 ` bg
Applicant/Agent's Signafure . _ Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 12 of 12
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October 9, 2002
Chatham County
DWQ Project No. 021558
APPROVAL of 401 Water Quality Certification
Mr. W. F. Rosser, P.E., Division Engineer
NCDOT, Division 8
PO Box 1067
Aberdeen, NC 28315
Dear Mr. Rosser:
You have our approval, in accordance with the attached conditions and those listed below, to place fill material in 60
linear feet of streams for the purpose of replacing an existing culvert and grading and paving SR 1131 in Chatham
County. The project shall be constructed in accordance with your application dated September 24, 2002. After
reviewing your application, we have decided that this fill is covered by General Water Quality Certification Number
3375. This certification corresponds to the Nationwide Permit 14 issued by the Corps of Engineers. In addition,
you should acquire any other federal, state or local permits before you proceed with your project including (but not
limited to) Sediment and Erosion Control, Non-Discharge and Water Supply Watershed regulations. This approval
will expire with the accompanying 404 permit, unless otherwise specified in the Water Quality Certification.
This approval is valid, solely for the purpose and design described in your application (unless modified below).
Should your project change, you must notify the DWQ and submit a new application. If the property is sold, the
new owner must be given a copy of this Certification and approval letter, and is thereby responsible for complying
with all the conditions. If total wetland fills for this project (now or in the future) exceed one acre, or of total
impacts to streams (now or in the future) exceed 150 linear feet, compensatory mitigation may be required as
described in 15A NCAC 2H.0506 (h) (6) and (7). For this approval toxemain valid, you must adhere to the
conditions listed in the attached certification.
1.) Upon completion of the project, the NCDOT shall complete and return the enclosed "Certification of
Completion Form" to notify DWQ when all work included in the 401 Certification has been completed. The
responsible party shall complete the attached form and return it to the 401/Wetlands Unit of the Division of
Water Quality upon completion of the project.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing. You must
act within 60 days of the date that you receive this letter. To ask for a hearing, send a written petition that conforms
to Chapter 150B of the North Carolina General Statutes to the Office of Administrative Hearings, P.O. Box 27447,
Raleigh, N.C. 27611-7447. This certification and its conditions are final and binding unless you ask for a hearing.
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
N. C. Division of Water Quality 1650 Mail Service Center Raleigh, NC 27699-1650 (919) 733-1786
Customer Service: 1 800 623-7748
Michael F. Easley, Governor
?OF wATFgQ William G. Ross Jr., Secretary
`O G North Carolina Department of Environment and Natural Resources
C/) 7 Alan W. Klimek, P.E. Director
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water Act. If you
have any questions, please contact John Hennessy at 919-733-5694.
incerely,
Alan W/.mek, P.E.
Attachment
cc: Wilmington District Corps of Engineers
Corps of Engineers Raleigh Field Office
DWQ Raleigh Regional Office
File `Copy
Central Files
c:\ncdot\SR 1131\wqc\021558wgc.doc
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY DIVISION OF HIGHWAYS
GOVERNOR
September 24, 2002
Mr. Rob Riding
Division of Water Quality
401 Wetlands Unit
1650 Mail Service Center
Raleigh, North Carolina 27699-1650
Dear Mr. Ridings:
Enclosed is the permit application for the following project:
Description: SR 1131 (Jim Page Rd) - Chatham
Work Order #: 6.522391
TIP Number: N/A
Fee Category: $200.00
Please submit for automated payment.
02155.0
LYNDo TIPPETT
SECRETARY
Q W
t
SEP 2 7
QUALIT7S?qlM
Q. _..... _ .._.._'
Sincerely,
C%ile
Art C. King
Division Environmental Officer
PAYMENT
RECEIVED
021558.
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY DIVISION OF HIGHWAYS
GOVERNOR September 24, 2002
Mr. Rob Ridings
Division Of Water Quality
401 Wetlands Unit
1650 Mail Service Center
Raleigh, NC 217699-1650
Dear Mr. Ridings:
Subject: Chatham County - SR 1131
LYNDO TIPPETT
SECRETARY
In an effort to obtain the permits needed for pipe replacement on SR 1131 in Chatham County,
we are providing the pre construction notification application and the supporting materials.
The project is on an intermittent stream that is outside of the critical habitat area for the Cape Fear
Shiner.
To our knowledge there are No High Quality Waters or Outstanding Water Resources occurring
in the project area. We anticipate that these activities will be authorized under Nationwide Permit
Number 14. Any detours required for this project will be done off site. NCDOT Best
Management Practices will be implemented during all construction projects.
This letter and a copy of the application materials will be submitted to N.C. Division of Water
Quality, U.S. Fish and Wildlife Service, and U.S. Army Corps. of Engineers for approval.
If you have any questions or comments, or need additional information, please contact our office
at (910) 944-2344. Thank you for your cooperation in this matter.
Sincerely,
Art C. King
Division Environmental Officer
cc: W. F. Rosser, PE
J. Picklesimer, PE
B. F. Sloan
File
P.O. BOX 1067, ABERDEEN, NORTH CAROLINA 28315
PHONE (910) 944-2344 FAX (910) 944-5623
021558
°
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Office Use Only: ®L 1 C c 8 Form Version October 2001
USACE Action ID No. DWQ No. J J
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
L
H.
Processing
1. Check all of the approval(s) requested for this project:
® Section 404 Permit
? Section 10 Permit
® 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
SEP 2 200?
2. Nationwide, Regional or General Permit Number(s) Requested: Nationwide #14
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 Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ?
Applicant Information
Owner/Applicant Information
Name: North Carolina Department of Transportation
Mailing Address: W. F. Rosser, P.E., Division Engineer
North Carolina Department of Transportation, Division 8
P.O. Box 1067
Aberdeen, North Carolina 28315
Telephone Number: 910-944-2344 Fax Number: 910-944-5623
E-mail Address: brosser(a dot.state.nc.us
2. Agent 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: Benny F. Sloan
Company Affiliation: NC Department of Transportation
Mailing Address: 1404 East Raleigh Street
Siler City, North Carolina 27344
Telephone Number: (919)742-3431 Fax Number: 919-742-3986
E-mail Address: bfsloan(a dot.state.nc.us
PAYMENT
R CEIVrr-
-5-
M. 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 afrow. 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: SR 1131 (Jim Page Rd)
2. T.I.P. Project Number or State Project Number (NCDOT Only): 6.522391
3. Property Identification Number (Tax PIN):
4. Location
County: Chatham Nearest Town: Siler City
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.): East on US 64, right on SR 1107
Travel 1.8 miles, left on SR 1100, travel 3.3 miles to SR 1130 and SR 1131 is on right.
5. Site coordinates, if available (UTM or Lat/Long): N35°40' 12" W79°30'40"
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this application:
Existing secondary road
7. Property size (acres):
8. Nearest body of water (stream/river/sound/ocean/lake): Brush Creek
9. River Basin: Cape Fear
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
-6-
10. Describe the purpose of the proposed work: Grade and pave SR 1131 in Chatham County
11. List the type of equipment to be used to construct the project: Motorgrader, trackhoe,
bulldozer, scraper, etc.
12. Describe the land use in the vicinity of this project: Residentiallagricultural
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.
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
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. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must 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.
-7-
1. Wetland Impacts
Wetland Impact
Site Number
indicate on map)
Type of Impact* Area of
Impact
acres Located within
100-year Floodplain**
(es/no Distance to
Nearest Stream
linear feet
Type of Wetland***
None
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized cleating, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http://www.femagov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc-)
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stream Impacts, including all intermittent and perennial streams
Stream Impact
Site Number
(indicate on map)
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
lease specify)
1 P 60' Brush Creek 27-3' 1
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net losdgain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, eta), excavation, ditchingfstraightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included
** Stream names can be found on USGS topographic maps. If a stream has no name list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
wvrw.usgs.gov. Several intemet sites also allow direct download and printing of USGS maps (e.g., wtirw.toyozone.com,
Nv%Nw.mgMuest.com. etc.
Cumulative impacts (linear distance in feet) to all streams on site: 60'
-8-
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S.
Open Water Impact
Site Number
(indicate on map)
Type of Impact* Area of
Impact
acres Name of Waterbody
..(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)
None
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging
flooding, drainage, bulkheads, etc.
4. 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.):
Size of watershed draining to pond: Expected pond surface area:
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.
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.
-9-
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, 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 determiniljg acceptability of appropriate and practicable
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 NCWRP 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/ncwetlands/stnngide.htm].
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.
N/A
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at http://h2o.enr.state.nc.u5in? Andex.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
-10-
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ® No ?
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
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 ?
M Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
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.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No ® If you answered "yes", provide the following information:
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.
*
Zone Impact
(square feet)
Multiplier Required
Mitigation
1 3
2 1.5
Total
Gone 1 extends out su teet perpendicular tram near bank of channel; Lone 2 extends an
additional 20 feet from the edge of Zone 1.
-11-
If buffer mitigation is required, plea e discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
XI. Stormwater (DWQ Only)
Describe impervious acreage (both 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.
Neither the current impervious cover (gravel road bed) nor the new proposed impervious cover
(asphalt pavement) will exceed 30% of the total site area Erosion control devices appropriate to j s
the site will be utilized on this project which may include silt fences check dams and storm
water retaining basins.
XII. Sewage Disposal (DWQ Only)
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.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 211.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? No
XIV. 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).
cl 2 ??- 6
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
-12-
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