20180706 Ver 1_401 Application_20180523

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 5/22/2018 11:23:01 AM (Message Start Event)
Accept by Carpenter,Kristi 5/23/2018 12:36:44 PM (DOT project)
. The task was assigned to Carpenter,Kristi. The due date is: May 25, 2018 5:00 PM
5/22/2018 11:23 AM

Staff Review
i�#*
20180706
Version* �
Is this project a public transportation project? *
Is this a DOT F Yes f No
project?*
Reviewer List:*
Select Reviewing Office:*
Submittal Type:*
401 Application
C•' Yes
�' No
Garcy Ward:eads\gpward
Washington Regional Office - [phone]
Does this project require a request for payment to be sent? *
r
Yes
r•
No
Water Resources
ENVIRONMENTAL �UPLITV

Project Submittal Dated 5/22/2018
*
Please note: fields marked with a red asterisk beloware required. You will not be able to submit the form until all
mandatory questions are ans�red.
Project Type:* �' New Project
C' Pre-Application Submittal
C' More Information Response
r Other Agency Comments
l•' For the Record Only (Courtesy Copy)
New Project - Please check the new project type if you are trying to submit a new project that needs an official approval
decision.
Pre-Application Submittal - Please check the pre-application submittal if you just want feedback on your submittal and
do not have the e�ectation that your submittal will be considered a complete application requiring a formal decision.
More Information Response - Please check this type if you are responding to a request for information from staff and
you have and ID# and version for this response.
Other Agency Comments - Please check this if you are submitting comments on an ebsting project.
Project Contact Information
Name: Paul Williams
Who is subrritting the irrforrration?
Email Address:* [e-mail]
Project Information
Project Name:* Courtesy Notification - Perquimans SR 1112 Hovvells Lane - Pipe Replacement
Is this a public transportation project? *
C•' Yes
C' No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?*
C' Ye�' No l' Unknown
TI P#: WBS#:
1.207211
(Applies to DOT projects only)
County (ies) *
Perquimans
Please upload all files that need to be submited.
C7ick the upload button or drag and drop files here to attach docurrent
Topo - SR 1112 Howells Lane RMIP 2019 -
1.03MB
Perquimans.pdf
Only pdf or krre files are accepted.
Describe the attachments:

This is a courtesy notification that NCDOT will be replacing a pipe in a jurisdictional area in Perquimans
County under Nationwide Permit 3 conditions. Location is on a UT to the Perquimans River, Stream Index No.
30-6-(1), Pasquotank River Basin.
E�sting 36" X40' CMP will be replaced by a 36" X40' CAP at N 36.20857° W 76.51368°.
* fJ By checking the box and signing box below, I certify that:
o I have given true, accurate, and complete information on this form;
o I agree that submission of this form is a"transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the
"Uniform Electronic Transactions AcY')
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions AcY');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the online form."
Signature:
r.sl�r�r/i �/i�" 1f/�IIiTlNci. f%T.
Submittal Date: