20200929 Ver 1_Modification Request Attachment_20210226 (3)

Proj ect Submittal In terim Form
Updated June 20, 2017
Please note: fields mark ed with a red asterisk * below are required. You will not be able to submit the form until all
mandatory questions are answered.
Proje ct Type :*
Ne w Proje ct - 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 expectation that your submittal will be considered a complete application requiring a formal decision.
M ore Information Re sponse - 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.
Othe r Age ncy Comme nts - Please check this if you are submitting comments on an existing project.
Name :
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Proje ct Name :*
Is this a public transportation proje ct?*
Is this a DOT proje ct?*
Is the proje ct locate d within a NC DCM Are a of Env ironme ntal Conce rn (AEC)?*
TIP#:WBS#:
County (ie s)*
New Project New Project with Existing ID
Pre-Application Submittal More Information Response
Other Agency Comments Stream or Buffer Appeal
For the Record Only (Courtesy Copy)
Project Contact Information
Steve Trowell
Who is submitting the inf ormation?
[e-mail]
Project Information
Courtesy Notification - Tyrrell County SR 1321 South Gum Neck Road Pipe
Replacement
Yes
No
Yes
No
Yes No Unknown
1B.208911
(Applies to DOT projects only)
Tyrrell
Ple ase upload all file s that ne e d to be submite d.
De scribe the attachme nts or add comme nts:
*
I have given true, accurate, and complete information on this form;
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 Act”)
I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the “Uniform Electronic Transactions Act”);
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
I intend to electronically sign and submit the online form.”
Signature :*
Submittal Date :
Click the upload button or drag and drop f iles here to attach document
Topo SR 1321 South Gum Neck Road near Cherry
Ridge Landing.pdf
1.09MB
Only pdf or kmz f iles are accepted.
This is a courtesy notification that NCDOT will be replacing a pipe in a jurisdictional area in Tyrrell County
under Nationwide Permit 3 conditions. Location is on an unnamed canal to connecting canals to Alligator
River, Stream Index No. 30-16-(7) Pasquotank River Basin.
Existing (2) 72" X 75' CMP will be replaced by (2) 84" X 80' CAPA at N 35.707020° W- 76.139590°.
By checking the box and signing box below, I certify that:
Is f illed in automatically once submitted.