20190720 Ver 1_401 Application (2)_20190604

Staff Review
Does this application have all the attachments needed to accept it into the review process?
r Yes r No
ID#* Version* 1
20190720
Is this project a public transportation project?* r Yes
r No
Is this a DOT r Yes r No
project?*
Reviewer List:*
Select Reviewing Office:*
Submittal Type:*
401 Application
Joanne Steenhuis:eads\jhsteenhuis
Wilmington Regional Office - [phone]
Does this project require a request for payment to be sent? *
r
Yes
c:
No

Project Submittal Form
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Type: r New Project
r Pre -Application Submittal
r More Information Response
r Other Agency Comments
r 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 expectation 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 existing project.
Project Contact Information
Name: Sean Farrell for NCDOT Division 3
Who is subrritting the information?
Email Address: [e-mail]
Project Information
Project Name: Sampson County SR 1920 Moltonville Road Hurricane Pipe Replacement Burial
Waiver Request
Is this a public transportation project?
r Yes
r No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
r Yes r No r Unknown
TIP#: WBS#:
DF 15403.2082014
(Applies to DOT projects only)
County (ies)
Sampson
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach docurrent
SR1920Moltonvile_BurialWaiver.pdf 4.26MB
Only pdf or kare files are accepted.
Describe the attachments:
Burial waiver request package containing pipe/streambed profile, Wetland Impact Summary, Topo Map,
LiDAR Map, and Soil Map.
V By checking the box and signing box below, I certify that:

• I have given true, accurate, and complete information on this form;
• 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 Act")
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 Act');
• 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:
Submittal Date: Is filled in automatically.