20190749 Ver 2_Brown Road permit completion form DWR_20201112

DocuSign Envelope ID:CB94E35F-8A16-4B7F-9D14-67A9A916AFFE
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ROY COOPER l mi�-. ,.;
Governor s,t. r col _fry
MICHAEL S.REGAN \\, nnr a
Secretary \'k`9u*1"""i
......._
S.DANIEL SMITH NORTH CAROLINA
Director II UA � Environmental Quality
NCDWR Project No.:�O6 \ -0.414gt).)County: S-Tk S
Applicant: k_k -0. ni- 0�'t/�LA a`i on 1
Project Name: S (ALT, "FL 60,-'ser-1— �Q �I
b(, Jt� j-g.-�(Sfnil.2/l )
Date of Issuance of 401 Water Quality Certification:Ac ��\ �L21
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,27699-1617. 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.
Applica is Certiftcat' t
I, ,hereby state that,to the best of my abilities,due care and diligence
wa us d in to o s the construction such that the construction was observed to be built within substantial
compliance and intent the 401 Water Quality Certification and Buffer Rules,the approved plans and
specifications,and of r suppo ' g materials.
Signature: Date: ( I/12/x)
Agent's Certificate°
1, ,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:
Engineer's Certification
Partial Final
I, ,as a duly registered Professional Engineer in the State of North
Carolina,having been authorized to observe(periodically,weekly, fitll 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
D_E Q North Carolina Department of
1617
nmental erviceCentey I Raleign of h.North
Water Resour
ces
512 North Salisbury Street 1617 Mail Service Center I Raleigh.North Carolina 2 76 9 9-1617
o,00nm,m ols.!...m..tw.ai; / 919.707.9000