20150035 Ver 4_W5516 404 permit completion form_20180612

Actian ID NumUcr: SAW-2013-01905 County: Ro�van
Permittee:
Project Na�ue:
NC DOT Div 9
Amy Euliss
NCDOT Old Betty Fol•d Raad (SR 1221) TIP W-5516
Date Vere�cation Issued: 01/15/2015
Project Man�ger: John Thamas
U�on completion of the activity a�thorized by this per�nit and any mitigation required by the pern�it,
si�n this certification and return it to the follo�ving address:
US ARMY CORPS OF ENGINEERS
WILMINGTON DYSTRICT
Attn: John Thomas
Raleigh Regulata�y Field Office
3331 Hee•itage Tr�de Drive, Suite 105
Wake Forest, North Carolin� 27587
Ple�se note that your permitted activity is subject to a campti�nce inspection by a U, S. Army Car�s of
Engineers representative. Failure to comply rvith �ny terms or conditions of this aufhorization may
result in tl�e Car�s sus�ending, modifying or revoking the �uthorization andlor issuing a Class I
ad�ninistrat'rve penalty, or initiating other �pp�•opriate legal action.
I hereby cea•tify tla�t the «�ork �uthorized by the above referenced permit h�s been completed in
�ccordance with the terms a�id cvnclition of the said permit, and required mitigation was compleied in
accordance ��vith the permit conditions.
�„ June 12, 2018
Sig���tur of Pcrmittee Date