20150330 Ver 1_Certification of Completion_20150904

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NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
NCDWR Project No.:
20/503 30
Applicant: /VC�D%� �!d Jr
co�nty: �ran,�l.h
ProjectName: S� l�PLSIS�✓►�on �o����e �2d)
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Date of Issuance of 401 Water Quality Certification: �//..f�
Donald van der Vaart
Secretary
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer Rules, and
any subsequent modifications, the applicant is required to return this certificate to the 401 Transportation Permitting
Unit, North Carolina Division of Water Resources, 1650 Mail Service Center, Raleigh, NC, 27699-1650. This form
may be returned to NCDWR by the applicant, the applicant's authorized agent, or the project engineer. It is not
necessary to send certificates from all of these.
Applieant's Certification
l, T/e. %'�o �.:�5 /`: � , hereby state that, to the best of my abilities, due care and diligence
was used in the ob ervation 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, a ther supp i materials.
Signature: � ' Date: ` � ��'�'' �✓
Agent's Certificatio
l, , 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.
Sibnature: Date:
Engineer's Certifieation
Partial Final
1, , as a duly registered Professional Engineer 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.
Date
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Phone: [phone] Internet: www.ncdenr.gov
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SEP - 4 2015
An Equal Opportuniry 1 Affrmative Action Employer DENR -WATER RESOURCES
TRANSPORTATION PERMITTIN� UNIT