U-5706_Merger_Application_2022.07.22.pdf

DocuSign Envelope ID: E7CCD63D-C22D-4B8E-BCOB-EO995lB4BCE9
U.S. Army Corps of Engineers (USACE)
Form Approved -
APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT
OMB No. 0710-0003
33 CFR 325. The proponent agency is CECW-CO-R.
Expires: 02-28-2022
The public reporting burden for this collection of information, OMB Control Number 0710-0003, is estimated to average 11 hours per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services,
at whs me-alex esd mbx dd-dod-information-collections(cilmail mil. Respondents should be aware that notwithstanding any other provision of law, no person shall
be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT
RETURN YOUR APPLICATION TO THE ABOVE EMAIL.
PRIVACY ACT STATEMENT
Authorities: Rivers and Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection, Research, and Sanctuaries Act,
Section 103, 33 USC 1413; Regulatory Programs of the Corps of Engineers; Final Rule 33 CFR 320-332. Principal Purpose: Information provided on this form
will be used in evaluating the application for a permit. Routine Uses: This information may be shared with the Department of Justice and other federal, state, and
local government agencies, and the public and may be made available as part of a public notice as required by Federal law. Submission of requested information
is voluntary, however, if information is not provided the permit application cannot be evaluated nor can a permit be issued. One set of original drawings or good
reproducible copies which show the location and character of the proposed activity must be attached to this application (see sample drawings and/or instructions)
and be submitted to the District Engineer having jurisdiction over the location of the proposed activity. An application that is not completed in full will be returned.
System of Record Notice (SORN). The information received is entered into our permit tracking database and a SORN has been completed (SORN #A1145b)
and may be accessed at the following website: Stp://dpcld defense gov/Privacy/ ORNslndex/DOD-wide-SORN-Article-View/Article/570115/al l45b-ce.as.0
(ITEMS 1 THRU 4 TO BE FILLED BY THE CORPS)
1. APPLICATION NO. 2. FIELD OFFICE CODE 3. DATE RECEIVED 14. DATE APPLICATION COMPLETE
(ITEMS BELOW TO BE FILLED BYAPPLICANT)
5. APPLICANT'S NAME 8. AUTHORIZED AGENT'S NAME AND TITLE (agent is not required)
First - Patrick Middle - Last - Norman First - Middle - Last -
Company - NCDOT - Division 8 Company -
E-mail [e-mail] E-mail Address -
6. APPLICANT'S ADDRESS: 9. AGENT'S ADDRESS:
Address- 121 DOT Drive Address -
City - Carthage State - NC Zip - 28327 Country - City - State - Zip - Country -
7. APPLICANT'S PHONE NOs. w/AREA CODE
10. AGENTS PHONE NOs. w/AREA CODE
a. Residence b. Business c. Fax
a. Residence b. Business c. Fax
910-773-8000
STATEMENT OF AUTHORIZATION
11 1 hereby authorize, to act in my behalf as my agent in the processing of this application and to furnish, upon request,
supplemental information in support of this permit application.
SIGNATURE OF APPLICANT DATE
NAME, LOCATION, AND DESCRIPTION OF PROJECT OR ACTIVITY
12. PROJECT NAME OR TITLE (see instructions)
U-5706 - Eastern Rockingham Corridor Study, from US 74 Business to SR 1426 (Aberdeen Road) in Richmond County
13. NAME OF WATERBODY, IF KNOWN (if applicable)
14. PROJECT STREET ADDRESS (if applicable)
multiple (see attached)
Address
15. LOCATION OF PROJECT
City - State- Zip-
Latitude: -N 34.9153 Longitude: -W 79.7338
16. OTHER LOCATION DESCRIPTIONS, IF KNOWN (see instructions)
State Tax Parcel ID Municipality
Section - Township - Range -
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17. DIRECTIONS TO THE SITE
From Raleigh, take US 1 South to Rockingham (94 miles). Follow Wiregrass Road (SR 1640) south (2.5 miles). Continue on County Home
Road (SR 1624) west to Clemmer Road (2.5 miles).
18. Nature of Activity (Description of project, include all features)
Project proposes improvements to connect US 74 Business in the southeastern part of the City of Rockingham to residential areas northeast of
the City along US 1 and SR 1423 (Richmond Road).
19. Project Purpose (Describe the reason or purpose of the project, see instructions)
The purpose of the project is to provide direct connectivity between commercial areas along US 74 Business and residential areas northeast of
central Rockingham and reduce conflicts between through traffic and local traffic on Long Drive.
USE BLOCKS 20-23 IF DREDGED AND/OR FILL MATERIAL IS TO BE DISCHARGED
20. Reason(s) for Discharge
Wetlands and streams will be impacted by construction activities, i.e., widening of existing roads and the replacement/extension of drainage
structures, and/or construction of new roads and the associated drainage structures.
21. Type(s) of Material Being Discharged and the Amount of Each Type in Cubic Yards:
Type Type Type
Amount in Cubic Yards Amount in Cubic Yards Amount in Cubic Yards
22. Surface Area in Acres of Wetlands or Other Waters Filled (see instructions)
Acres See attached information
or
Linear Feet
23. Description of Avoidance, Minimization, and Compensation (see instructions)
See attached information
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24. Is Any Portion of the Work Already Complete? ❑ Yes ®No IF YES, DESCRIBE THE COMPLETED WORK
N/A
25, Addresses of Adjoining Property Owners, Lessees, Etc., Whose Property Adjoins the Waterbody (if more than can be entered here, please attach a supplemental list).
a. Address- See attached mailing labels
city - State - Zip -
b.Address-
city - State - Zip -
c. Address -
City - State - Zip -
d. Address -
City - State - Zip -
e. Address -
City - State - Zip -
26. List of Other Certificates or Approvals/Denials received from other Federal, State, or Local Agencies for Work Described in This Application.
AGENCY TYPE APPROVAL' IDENTIFICATION DATE APPLIED DATE APPROVED DATE DENIED
NUMBER
Would include but is not restricted to zoning, building, and flood plain permits
27. Application is hereby made for permit or permits to authorize the work described in this application. I certify that this information in this application is
complete and accurate. I further certify that I possess the authority to undertake the work described herein or am acting as the duly authorized agent of the
applicant.Docusigned by:
PafVi& 4V1MAdn, 7/22/2022 _
eNIA4119REPOF APPLICANT DATE SIGNATURE OF AGENT DATE
The Application must be signed by the person who desires to undertake the proposed activity (applicant) or it may be signed by a duly
authorized agent if the statement in block 11 has been filled out and signed.
18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of the United States
knowingly and willfully falsifies, conceals, or covers up any trick, scheme, or disguises a material fact or makes any false, fictitious or fraudulent
statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious or fraudulent
statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both.
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