20150821 Ver 1_Certification of Completion_20160527

Action ID Number: SAW-2015-01788 County: Stokes
Permittee:
Project Name:
NC DOT Div 9
Stenhanie Brapuet
NC DOT Br 103 SR 1707 Bridge to Culvert Div 9 Stokes Co
Date Verification Issued: 08/17/2015
Project Manager: John Thomas
Upon completion of the activity authorized by this permit and any mitigation required by the permit,
sign this certification aad return it to the following address:
US ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Attn: John Thomas
Raleigh Regulatory Field Office
3331 Heritage Trade Drive, Suite 105
Wake Forest, NC 27587
Please note that your permitted activity is subject to a compliance inspection by a U. S. Army Corps of
Engineers representative. Failure to comply with any terms or conditions of this authorization may
result in the Corps suspending, modifying or revoking the authorization and/or issuing a Class I
administrative penalty, or initiating other appropriate legal action.
I hereby certify that the work authorized by the above referenced permit has been completed in
accordance with the terms and condition of the said permit, and required mitigation was completed in
accordance with the permit conditions.
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Signa ur of Permittee
�� �
Date

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NCDENR
North Carolina Department of Environment and Natural Resources
Pat �9cCrory
Governor
NCDWR Project No.:
Applicant: ��`C
Project Name:
County: S'FO��P.S
Donald R. van der Vaart
Secretary
- v -
Date of Issuance of 401 Water Quality CertiScation: 5��� �(7 ��
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Certiticate 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 Cazolina Division of Water Resources, 1617 Mail Service Center, Raleigh, NC, 27699-1617. This form
may be retumed to NCDWR by the applicant, the applicanYs authorized agent, or the project engineer. It is not
necessary to send certificates from all of these.
Applicant's Certification
�, ll...,t,�f Gt � S 3 , hereby state that, to the best of my abilities, due care and diligence
was'ii sed in t}ie 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 ther sup orting materials.
/ ��� /�
Signature: Date:
AgenNs Certification
I, , hereby state that, to the best of my abilities, due caze and diligence
was used in the observation of the consiruction such that the conshuction 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:
Engineer's Cenification
Par[ial
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 consh�uction 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 substanrial compliance and intent of the 40l
Water Quality Certification and Buffer Rules, the approved plans and specifications, and other supporting materials.
Signature
Date
Registration No.
1617 Maii Service Center, Raleigh, 'lodh Carolina 27699-1617
Phone:[phone]ntemet www.ncdenr.go,
AnEqualCpportun4y J.RrmaV.=Fc6onEmployer