20190105 Ver 1_401 Application (2)_20190123

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#* Version* �
20190105
Is this project a public transportation project? * r Yes
l' No
Is this a DOT C•' Yes l' No
project?*
Reviewer List:* Garcy Ward:eads\gpward
Select Reviewing Office:* Washington Regional Office -[phone]
Submittal Type:*
401 Application
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: Paul Williams
Who is subrritting the irrforrration?
Email Address: [e-mail]
Project Information
Project Name: Courtesy Notification - Hertford SR 1441 Swains Mill Road - Pipe Replacement
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#:
1.204611
(Applies to DOT projects only)
County (ies)
Hertford
Please upload all files that need to be submited.
aick the upload button or drag and drop files here to attach docurrent
Topo SR 1441- Swains Mill Road Emergency Pipe
1.34MB
Replacement- Hertford.pdf
Only pdf or Ivre files are accepted.
Describe the attachments:

This is a courtesy notification that NCDOT will be replacing a pipe in a jurisdictional area in Hertford
County under Nationwide Permit 3 conditions. Location is on a UT to Deep Swamp Branch (Taylor Pond),
Stream Index No. 25-16, Chowan River Basin.
E�sting 36" x 54' RCP will be replaced by a 42" x 56' CAP at N 36.301539° W 76.721081
fJ By checking the box and signing box below, I certify that:
o I have given true, accurate, and complete information on this form;
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:
. s13r�r/[ �frir' %fffiTlNci . f �/J.
Submittal Date: