20080432 Ver 1_Application_20080311

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STATE of NORTH CAROLINARR9,~y
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY LYNDO TIPPETT
GOVERNOR SECRETARY
March 5, 2008
N.C. Division of Water Quality
Transportation Permitting Unit
2321 Crabtree Blvd./Suite 250 O $ 0
Raleigh, NC 27604-2260
Attention: Mr. Rob Riding, NCDOT Project Coordinator
Subject: Secondary road improvements to SR 2707 (Bryan Road) from SR 2706
(Clifford Road) to SR 2709 (Ackerman Road) in Wake County. WBS
element SC.092085.
The North Carolina Department of Transportation (NCDOT) proposes to upgrade and
pave SR 2707 (Bryan Road) from SR 2706 (Clifford Road) to SR 2709 (Ackerman Road)
in Wake County (Figure 1 - 3). Total project length is 1.02 miles. Transportation and
highway laws of North Carolina (G.S. 136-44.6, 136-44.7, 136-44.7A, 136-44.8, and
136-44.9) require the NCDOT to develop annual work programs for construction and
maintenance of secondary roads. These general statutes specifically set forth
requirements for annual construction and paving of existing unpaved roads. Paving of
these roads is performed in priority order as established by the NCDOT for each unpaved
road within a given county. This number is based on characteristics of each road,
including number of homes, schools, churches, businesses, industries, recreational
facilities, traffic counts, presence of school bus routes, and value as a thoroughfare.
SR 2707 is scheduled to be paved as part of the Secondary Roads Construction Program.
Impacts to Waters of the United States
The project crosses a perennial stream, UT to Mahlers Creek, [NCDENR-DWQ Index Iv'o.
27-43-9, Best Usage Classification C NSW; HUC 03020201] in the Neuse River Basin. The
existing structure conveying the creek is a 60-inch metal pipe that is 37 feet long (see
Photographs 1 and 2). This pipe will be replaced with a 112" x 75" metal pipe arch that is
60 feet long. Permanent impacts at the site associated with the pipe replacement tota123ft _
of surface water fill, plus 42 feet of stream loss due to a necessary channel change.
Additionally, a total of 46 feet of rip rap is proposed. along the stream banks. Please note
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that the 36ft of rip rap along the outlet is provided as worse case to provide stability
around the pipe end _and along the channel change section. Armoring- the sides of the
entire 36 ft may not be necessary, perhaps only rock around the pipe end, tie in points
and%or the curves will be sufficient.. Field conditions during construction will reveal
Division 5, 2612 N. Duke Street, Durham, NC 27704
Phone: [phone] Fax: (9i9) 560-3371

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which best. The work zone at this site will be temporarily dewatered for approximately
3 days. As necessary, to maintain water flow during construction, water upstream of the
sandbags 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 and
the channel change work will follow. Temporary concurrent impacts to the stream from
this activity will result in dewatering 69.5 linear feet of stream. The materials used for
dewatering will be removed a er c n. Also please note that the soil survey
indicates the presence of hydric soils (Wo - Wehadkee and Bibb soils) at this crossing.
However no wetland areas exist within the project limits at Site 1. Therefore, this project
~pro~oses no iriapacts to wetlands.
Riparian Buffer
The activity at this site involves a road crossing of a stream that is subject to the Neuse
River Buffer Rules. The perennial tributary to Mahlers Creek, at Site 1 is depicted on the
most recent version of the Garner (USGS 1964/1987) topographic quadrangle (Figure 1)
and the Soil Survey of Wake County (USDA-SCS, 1970) (Figure 2). Construction
impacts at this site total 4,112 ft2 in Zone 1 and 2,427 ft2 in Zone 2 (totaling 69.5 lft of
riparian buffer impacts). ---
Waters of the U.S. Mitigation
Avoidance: All wetlands and surface waters not affected by the project will be protected
from unnecessary encroachmerrt. 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 Miti ation: Due to the minimal impacts proposed, no mitigation
requirements are anticipated. Therefore, NCDOT proposes no compensatory mitigation.
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 ESA. As of March 2008, there are three federally protected species listed for
Wake County. They include the red-cockaded woodpecker (Picoides borealis), dwarf
wedgemussel (Alasmidonta heterdon), and Michaux's sumac (Rhtrs michai~xii). Please note
that the bald eagle (Haliaeettrs leucocephali~s) was delisted as of August 20, 2007 and is no
longer protected by the Endangered Species Act. It is however, protected under the Bald and
Golden Eagle Protection Act. This project will have no effect on the bald eagle since no
habitat is present in the project area. The dense mixed hardwood stands surrounding the

3
project does not offer suitable forging or nesting habitat for red-cockaded woodpecker. This
UT to Mahlers Creek at Site 1 is a small stream and does not provide suitable habitat for
mussel fauna. The roadway shoulders along Bryan Road are in spots either heavily
maintained or overgrown, eliminating the possibility for Michaux's sumac to exist in this
area. Additionally, a review of the Natural Heritage Program database (last updated February
2008) revealed no occurrences of protected species within the project area. Therefore, based
on lack of suitable habitat observed during the 05/15/07 site visit and the NHP database
review, biological conclusions of No Effect have been rendered for each species.
Historical Compliance
This project has been screened by all pertinent parties to ensure historic compliance. A no
comment-no historic properties clearance was received from Renee Gledhill-Earley with
the NCSHPO, dated 03/18/04.
Summary
Application is hereby made for a NCDENR-DWQ Section 401 Water Quality
Certification (WQC) No. 3627 and riparian buffer authorization for above-described
activities. An automated payment procedure has been implemented between the NCDOT
and NCDWQ. 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 NCDWQ by charging the permit application fee of $200.00 directly to the appropriate
NCDOT WBS element SC.092085. Apre-construction notification is attached with this
request.
Per General Condition 27 [Notification provision], the USACE is not copied on this
permit request. The proposed activities meet the conditions of the Department of the
Army Section 404 Nationwide Permit (NWP) 14 and the proposed impacts do not exceed
the 1/10 acre of loss of Waters of the United States. Additionally this project does not
involve impacts to a special aquatic site. Therefore we intend to comply with all
applicable NWP conditions during construction of this project, working under NWP 14
with no notification required to the USACE.
If you have any questions or need additional information, please contact IV1s. Heather
Montague at [phone].
Sincerely,
J.W. Bowman, P.E.
Division Engineer
cc: Mr. Reid Elmore, NCDOT District 1 Engineer
Mr. Steve Halsey, NCDOT Wake County Maintenance Engineer
Mr. Tim Robbins, NCDOT Roadside Environmental Field Ops Technician

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fior dewatering ~ \
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roadway width
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extra pi e
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Note:
-BZ Buffer Zone
® Proposed surface water fill
~;;,;;;;, Proposed rip rap
-ETF Existing Transportation Facilit
• Construction Limit Fencing
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Site I- Construction Plan
SR 2707 Bryan Road
Wake County
Figure 3 I"=30'

Office Use Only: Form Version March OS
USACE Action ID No. DWQ No. 2 0 8 0 4 3 2
(If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A".)
I. 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 14 (non-reporting
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: ^
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
Name: NCDOT Division 5 J.W. Bowman
Mailing Address: 2612 N. Duke St. Durham NC 27704
Telephone Number: (919) 22-4600 Fax Number: [phone]
E-mail Address: wbowman~,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 Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
Paae I 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 maybe included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USAGE 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: Upgrading_and having SR 2707 (Bryan Road) in Wake County.
2. T.I.P. Project Number or State Project Number (NCDOT Only): WBS # SC.092085
3. Property Identification Number (Tax PIN): N/A
4. Location
County: Wake Nearest Town: Garner
Subdivision name (include phase/lot number): N/A
Directions to site (include road numbers/names, landmarks, etc.): From the US 70/Jones
Sausage Road intersection on the SE side of Garner take SR 2547 (Jones Sausage Road)
south for approximately 0.9 mile. Then make a right onto SR 2707 (Bryan Road -paved
section) and travel approximately 1 3 miles to intersection with SR 2709 (Ackerman Road).
Site one is approximately 200ft south of the SR 2707/SR 2709 intersection.
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):
Site 1: 35.6990 °N 78.5938 °W
6. Property size (acres: 7 4 acre (Project is 1 02 mi long)
7. Name of nearest receiving body of water: UT to Mahlers Creek
8. River Basin: Neuse
(Note -this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http•//h~o enr state.nc.us,/admin/maps/.)
9. Describe the existing conditions on the site and general land usa in the vicinity of the project
at the time of this application: Site is surrounded by wooded areas and residences.
Page 2 of 8

10. Describe the overall project in detail, including the type of equipment to be used: Grade,
drain, pave, and erosion control at SR 2707 (Bryan Road). The NCDOT will also dewater
the work site during construction. Equipment may include excavator, backhoe, bulldozer,
grader, and crane.
11. Explain the purpose of the proposed work: The project is part of the secondar ry oad paving
program. The existing_g_ravel roadway will be paved with asphalt.
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. NONE
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. 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: At Site 1 the existing_pipe will be
r~laced with longer length pipe impactingL surface waters. Due to the alignment of the
stream a slight channel change will be necessary. The NCDOT will also dewater the work
site during construction.
Page 3 of 8

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,
separately list impacts due to both structure and flooding.
Wetland Impact Type of Wetland Located within Distance to Area of
Site Number Type of Impact (e.g., forested, marsh, 100-year Nearest Impact
(indicate on map) herbaceous, bog, etc.) Floodplain Stream (acres)
(yes/no) (linear feet)
N/A N/A N/A N/A N/A N/A
Total Wetland Impact (acres) N/A
3. List the total acreage (estimated) of all existing wetlands on the property: NONE
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, dam
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
must be included. To calculate acreage, multiply length X width. then divide by 43.560.
Stream Impact _ Perennial or Average Impact Area of
Number Stream Name Type of Impact
' Stream Width Len th
g Im act
p
(indicate on map) Intermittent
? Before Impact (linear feet) (acres)
Site 1 UT to
Mahl
rs C
k Fill (piped length) perennial 3.0 23 0.0015
e
ree concurrent concurrent
Stream loss due to 42 0.003
channel move concurrent concurrent
Rip rap armoring 46 0.003
along stream bank concurrent concurrent
Temporary

dewatering 69.5 0.005
Total Stream Impact (by length and acreage) 69.5 0.005
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
fill, excavation, dredging, flooding, drainage, bulkheads, etc.
Open Water Impact
Name of Waterbody Type of Waterbody Area of
Site Number (if applicable) Type of Impact (lake, pond, estuary, sound, bay, Impact
(indicate on map) 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): ~ 4.005
Wetland Impact (acres): NONE
Open ~'~'ater Impact (acres): NGNE
Total Impact to Waters of the-U.S. (acres) ~ 0.005
Total Stream >fmpact (linear feet): 69.5
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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 USACE.
N/A
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.
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 ire 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
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
Page 5 of 8

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/ncwetlands/strmgide.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.
No compensator.~g~ation is anticipated or proposed.
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
[phone] 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/wr~lindex.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): N/A
Amount of buffer mitigation requested (square feet): N/A
Amount of Riparian wetland mitigation requested (acres): N/A
Amount ofNon-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 [phone] to review current thresholds for environmental documentation.
Yes ^ No
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 ^
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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
tnap, 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
Mitigation
1 4,112 3 (2 for Catawba) N/A
2 2,427 1.5 N/A
Total 6,539 N/A
* Zone 1 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 3.21 acre existing impervious surface (avg 26 foot wide
gavel road, 1.02 mile uroiect) of the 7.4 acre nroiect size. The proposed impervious surface is
LESS with ~ 5 acre (proposed 20 foot wide asphalt paved road 1.02 mile project) of the 7.4 total
project size Erosion and sediment control devices along the ~roiect are comprised of temporary,
rock silt checks temporary silt basins and temporary silt fence.
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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.enr.state.nc.us/ncwetlands. If no, please provide a short narrative description:
Upgrading SR 2707 will not result in additional development.
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).

Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
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