20151120 Ver 1_Certification of Completion_20160711

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NCDWR Project No.: ZOIS �IZO
Applicant: �VC�O� • r-�rry �'•�%►S�
Project Name:
Date of Issuance of 401 Water Quality
PAT MCCRORY
Go�en�or
DONALD R. VAN DER VAART
Secrclnn
S. JAY ZIMM�RMAN
County:
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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, 1617 Mail Service Center, Raleigh, NC, 27699-] 617. 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.
Applicant's Certifrcation
I, �,,o��lne��he 1�ee1e. , hereby state that, to the best of my abilities, due care and diligence
was used in the observation of the cons�uction 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, an other supporting materials.
Signature: ��IOL/(� Date: � �v / (o
Agent's Certification
I, , 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 substanrial
compliance and intent of the 401 Water Qua(ity Certification and Buffer Rules, the approved plans and
specifications, and other supporting materials.
Signature:
Engineer's Certifrcation
Partial
Fina1
Date:
I, , 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
Date
Registration No.
State of North Carolma (Env�ronmental Qual�ty � Water Resources
1677 Mal Service Center, Ralegh, NoAh Carolma 27699-1617
Phone [phone]

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