20190531 Ver 2_401 Application_20210630

Staff Review Form Is
Updated September
Staff Review
Does this application have all the attachments needed to accept it into the review process?*
r Yes r No
ID#* Version* 2
20190531
Is this project a public transportation project?* r Yes
r No
Is this a DOT r Yes r No
project?*
Reviewer List:* Rob Ridings:eads\rgridings
Select Reviewing Office:* Central Office-[phone]
Does this project require a request for payment to be sent?
r
Yes
r
No

Project Submittal Form
Please note:fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Type:* r For the Record Only(Courtesy Copy)
r New Project
r Modification/New Project with Existing ID
r More Information Response
r Other Agency Comments
r Pre-Application Submittal
r Re-Issuance\Renewal Request
r Stream or Buffer Appeal
Pre-Filing Meeting Information
Pre-Filing meeting request information is not needed for this project.
Project Contact Information
.......................................................................................................................................................................................................................................................................................................................................................................................................
Name: Chad Coggins
Who is submitting the inforrration?
Email Address: [e-mail]
Project Information
.......................................................................................................................................................................................................................................................................................................................................................................................................
Existing ID M Existing Version:
20195031 1
20170001(no dashes) 1
Project Name: Bridge No.64 Over Town Creek on SR 1126(Faith Baptist Church Rd.)
Is this a public transportation project?
r Yes
r No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
r Yes r No r Unknown
TIP#: WBS#:
B-60002 48197.3.1
(Applies to DOT projects only)
County(ies)
Edgecombe
Please upload all files that need to be submited.
Gick the upload button or drag and drop files here to attach docurrent
Edgecombe_64_Permit_Drawings Mod 06 29
1.11M6
2021.pdf
Only pdf or Iv17 files are accepted.

Describe the attachments
or comments:
Please see the attached permit drawings for bridge 64 over Town Creek in Edgecombe County,the purpose
of this submittal is to request a modification of the permit to enable temporary dewatering and, if necessary, a
temporary causeway to facilitate the removal of interior bents;these activities will be conducted in such a
manner to ensure that no more than 50 percent of the stream width is impacted at any given time.
Sign and Submit
......................................................................................................................................................................................................................................................................................................................................................................................................
W By checking the box and signing box below, I certifythat:
■ I,the project proponent, hereby certifies that all information contained herein is true,accurate, and complete to
the best of my knowledge and belief.
■ I,the project proponent, hereby requests that the certifying authority review and take action on this CWA 401
certification request within the applicable reasonable period of time.
■ I agree that submission of this online 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');
■ 1 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:
& � WeW
Submittal Date: Is filled in autorratically.