20190088 Ver 1_401 Application_20190122

Water Resources
ENVIRONMENTAL �UPLITV
Staff Review
Does this application have all the attachments needed to accept it into the review process?
C•' Yes C' No
ID#*
20190088
Version* �
Is this project a public transportation project? *
Is this a DOT C•' Yes l' No
project?*
Reviewer List:*
Select Reviewing Office:*
Submittal Type:*
401 Application
r Yes
l' No
Joanne Steenhuis:eads\jhsteenhuis
Wilmington Regional Office - [phone]
Does this project require a request for payment to be sent? *
l'
Yes
r
No

Project Submittal Form
*
Please note: fields marked with a red asterisk beloware required. You will not be able to submit the form until all
mandatory questions are ans�red.
Project Type: �' New Project
C' Pre-Application Submittal
C' More Information Response
r Other Agency Comments
l•' For the Record Only (Courtesy Copy)
New Project - Please check the new project type if you are trying to submit a new project that needs an official approval
decision.
Pre-Application Submittal - Please check the pre-application submittal if you just want feedback on your submittal and
do not have the e�ectation that your submittal will be considered a complete application requiring a formal decision.
More Information Response - Please check this type if you are responding to a request for information from staff and
you have and ID# and version for this response.
Other Agency Comments - Please check this if you are submitting comments on an ebsting project.
Project Contact Information
Name: Jim Rerko
Who is subrritting the irrforrration?
Email Address: [e-mail]
Project Information
Project Name: Replacement of Culvert No. 080202 on NC 210 over Smith Mill Pond Run
Is this a public transportation project?
�' Yes
�' No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
C' Ye�' No l' Unknown
TI P#: WBS#:
15406.1009013
(Applies to DOT projects only)
County (ies)
Bladen
Please upload all files that need to be submited.
aick the upload button or drag and drop files here to attach docurrent
Culvert 080202 PCN Cover Letter.pdf 430.24KB
080202_Permits_Combined.pdf 1.78MB
Only pdf or Ivre files are accepted.
Describe the attachments:
Cover Letter and Permit Drawings for Culvert 080202 Bladen County (Hurricane Florence Emergency Repair)
rJ By checking the box and signing box below, I certify that:
� �_.._ _:..__ ._..- ---..__._ __� __.__�_._ :_r__.__.:__ __ .�:_ �__._.

o i nave yroen uue, a�curaie, anca cuin�ieie inwnnauun un inis iu�rn,
o I agree that submission of this form is a"transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the
"Uniform Electronic Transactions AcY')
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions AcY');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the online form."
Signature:
�tr�c'tf %x�� ���tr. "rr.^
Submittal Date: