20150873 Ver 1_404_Completion Form_200_20171017

Action ID Number: SAW-2015-01907 County: Alamance
Permittee: NCDOT (attn: Jerrv Parker)
Project Name: NCDOT / SR 1110 / Brid�e 200 / Division 7/ Alamance Countv
Date Verification Issued: 9/16/2015
Project Manager: David Bailev
Upon completion of the activity authorized by this permit and any mitigation required by the permit,
sign tliis certi�cation and return it to the following address:
US ARMY CORPS OF ENGIN��RS
WILMINGTON DISTRICT
attn: David Bailey
Raleigh Regulatory Field Of6ce
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
Please note that your permitted activity is subject to a compliance inspection Uy a U. S. Army Corps of
Engineers representative. Failure to comply with any terms or conditions of this authorization may
result in the Corps suspending, modifying or revoking the authorization and/or issuing a Class I
administrative penalty, or initiating other appropriate legal action.
I hereby certify that the work authorized by the above referenced permit has been completed in
accordance with the terms and condition of the said permit, and required mitigation was completed in
accordance with the permit conditions.
� a�.J �o ��3—�fL7
5ignat re Permittee Date