20171328 Ver 1_Certification of Completion_20181128

CERTIFICATE OF COMPLETION
NCDWR Project No.:--
County: ✓
Applicant:
Project Name: s' f �� T✓4-5, I L I Z A -Tl C,1131
Date of Issuance of 401 Water Quality Certification: 117
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
Transportation Permitting Unit, North Carolina Division of Water Resources, 1650 Mail Service Center,
Raleigh, NC, 27699-1650. 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
I, ` 4ly/ - / 4- -,�/17f 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 ands ecifications, 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 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
�kW 147Y�Jt
Registration No. Date
J- All P
State of North Carolina I Environmental Quality I Water Resources
512 N. Salisbury Street 1 1611 Mail Service Center I Raleigh, NC 27699-1611
919.707.9000