20151074 Ver 2_W-5313 401 permit completion form_20201215

[NMI lrr vrrrru ."v it
Pal McCrory
Governor
Donald R. van der Vaarl
Secretary
NCDWRProject No.: )--[)` 164LA County: k
Applicant: IJC:)Q 2
Project Name: 04, %e1ivt s� 1' . V1rC�,A06- le /l `Z 0). 31 .�
1
Date of Issuance of 401 Water Quality Certification: k)QIJ, Sj 1 .-c2 d J/
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.
Applicant'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 substantial
compliance and intent of the 401 Water Quality Certification and Buffer Rules, the approved plans and
specificationsnd gthier supporting materials.
Signature:
Agent's Certification
, 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
Date:
1, , 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 Registration No.
Date
1617 Mail Service Cenler, Raleigh, North Carolina 2769 i-1617
Phone 919-80; -6300 \ Interned www.ncdenr ciav
-n Equal CIpporhnut t. (iinnar,,r,; z, rion Ergduyer