20151042 Ver 1_Certification of Completion_20160607

North Carolina Department o
Pat McCrory � [I @ u
Governor JUN 77 2016
Donald R. van der Vaart
Secretary
DWR Project No.: S �� 0 1-1 12— County: C AL
Applicant: �A K c,S M v nr&
Project Name: p1Q -(S V'wrL o F q,3 1 we:)rwe� Q C e. e%. �,-O
Date of Issuance of 401 Water Quality Certification: o _ Z _ Z,a I
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 and Buffer Permitting Unit, North
Carolina Division of Water Resources, 1650 Mail Service Center, Raleigh, NC, 27699-1650. This form may be returned to
DWR by the applicant, the applicant's authorized agent, or the project engineer. It is not necessary to send certificates from
all of these.
Applican 's Certification
I, Vkvvt" M o nrcm , 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: "T0 1,2Date: '57-2- ig`t to
Agent's Certification
I, Kowe, , 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:
If this project was designed by a Certified Professional
I, N o AJ C-,- , as a duly registered Professional (i.e., Engineer, Landscape
Architect, Surveyor, etc.) in the State of North Carolina, having been authorized to observe (periodically, weekly, full time)
the construction of the project, for the Permitee 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
401 & Baffer Permitting Unit
1650 Mad Service Center, Raleigh, North Carolina 27699-1650
Phone [phone] FAX. [phone]
Internet http liportal ncdenr orglweblwglws
An Equal Opportunity 1 Affirmative Acton Employer