20180105 Ver 1_Certification of Completion_20180917

NCDWR Project No
Applicant:
CERTIFICATE OF COMPLETION
pQy r id 15-01,95
' Com-
County: L1 YI,:-Gl Y%
Project Name: c sC!Z f '+— peui i o
Date of Issuance of 401 Water Quality Certification:
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification (including planting of trees) or
applicable Buffer Rules, and any subsequent modifications, the applicant is required to return this certificate to
the 401 & Buffer Permitting Branch, North Carolina Division of Water Resources, 1617 Mail Service Center,
Raleigh, NC, 27699-1617. This form may be returned to NCDWR 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
Olyi; SCO+}— , 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 ther supporting materials.
Signature: 01�W�' 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 Buffer Rules, the approved
plans and specifications, and other supporting materials.
Signature:
Engineer's Certification
Partial Final
Date:
I, , as a duly registered Professional Engineer 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 Buffer Rules, the approved plans and specifications, and other supporting
materials.
Signature Registration No. Date