20160250 Ver 1_Certification of Completion_20161230

Water Resources : LA -1 1 V
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
ENVIRONMENTAL OUALITV
_D Project No.: 025c) County: Director
Applicant: 1 ln-(r-s n/J
Project Name: pG)c X 5k DEC i1
2016
Date of Issuance of Wetland Permit:,
Upon completion of all work approved within the 401 Water Quality Certification and/or Buffer Ru es,
subsequent modifications, the applicant is required to return this certificate to the 401 & Buffer Permitting Unit,
North Carolina Division of Water Resources, 1617 Mail Service Center, Raleigh, NC, 27699-1617. 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.
Applicant's Certification
I,SQY1(`(�, E. LA10\UC[1S, 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/or Buffer Rules, the approved plans
and specifications, and other supporting materials.
Signature: �. Date:
Agent's Certification
I, , 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 /or Buffer Rules, the approved plans
and specifications, and other supporting materials.
Signature: Date:
If this project was designed by a Certified Professional
I, , 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 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 substantial compliance and intent of the 401 Water Quality Certification and/or Buffer Rules, the
approved plans and specifications, and other supporting materials.
Signature:
Registration No.
Date
State of North Carolina I Environmental Quality I Water Resources —Water Quality Regional Operations—Washington Regional Office
943 Washington Square Mail, Washington, NC 27889
252-946-6481