20150394 Ver 1_404_Completion Form_253_20171017

Action ID Number: SAW-2015-00943 County: Alamance
Permittee: NCDOT (attn: Jerrv Parker)
Project Name: NCDOT / SR 2178 / Brid�e 253 / Division 7
Date Verification Issued: 5/8/2015
Project Manager: David Bailev
Upon completion of the activity authorized by this permit and any mitigation required by the permit,
sign this certi�cation and return it to the following address:
US ARMY CORPS OF ENGIN��RS
WILMINGTON DISTRICT
attn: David Bailey
Raleigh Regulatory Field Office
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 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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ig ture of Permittee
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Date