20110369 Ver 1_401 Application_20110411

Michael Baker Engineering, Inc.
8000 Regency Parkway
Suite 200
Cary, North Carolina 27518
Phone: [phone]
Fax: [phone]
TO: NC Division of Water Quality
Archdale Building, 9th Floor
512 North Salisbury Street
Raleigh, NC 27640
ATTENTION: Ms. Laurie Dennison
DATE: April 18, 2011
LETTER OF TRANSMITTAL
201 10369
RE: Bog Turtle Stream Enhancement Project
401/404 PCN Application
1
A
JOB NO. 117631 ?'
We are sending via:
0 Fax Regular Mail F-] Pick-up 0 Hand Delivered
The following items:
Correspondence F_x] Plans F-1 Specifications 0 Other as listed below:
COPIES DATE NO. DESCRIPTION
5 Design Plans
5 PCN form and attachments
5 Agent Authorization Form
1 Fee $570.00

THESE ARE TRANSMITTED as checked below:
e For Approval As Requested HApproved Approved As Submitted B Returned For Corrections
For Your Use X For Permitting As Noted Forward To Subcontractor
REMARKS:
Please find enclosed an application for DWQ's 401 Permit along with supporting documentation for the Bog
Turtle Stream Enhancement Project in Surry County. If you have any questions, please call me at [phone].
COPY TO: File
SIGNED: Joshua White
?R@[901619 1
APR 1 8 2011
UENR • WATER QUALITY
WETLANDS AND STORMATER BRANCH
611chael Baker Engineering, Inc.
8000 Regency Parkway
® Sui18 200
® ?+ Cary, North Coroino 27518
Phase. 919.483.5458
Fa)c 919.463.5490
April 15, 2011
Mr. Monte Matthews
Raleigh Regulatory Field Office
Department of the Army, Corps of Engineers
3331 Heritage. Trade Drive, Suite 105
Wake Forest, NC 27587
Ms. Laurie Dennison
NC Division of Water Quality
401/Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
Re: Bog Turtle Stream Enhancement Project
401/404 Pre-Construction Notification Application
Dear Mr. Matthews and Ms. Dennison:
Enclosed for your consideration and approval is the Pre-Construction Notification for the US Army Corps
nationwide permit 27 and the Division of Water Quality's general certification 3689 for stream enhancement,
and stabilization for the Bog Turtle Stream Enhancement Project. This project is located in Surly County. Also
enclosed are copies of the Bog Turtle Stream Enhancement Plan for your reference in reviewing the PCN
application. Thank you in advance for your assistance.
The project meets the DWQ definition of stream restorationlenhancement activities greater than
150 feet and funding was provided by Wildlife Habitat Incentives Program. Therefore a permitting
fee has been included with this package. This is not a stream mitigation project.
If I can be of any further assistance, please contact me at [phone].
Sincerely,
Joshua White, PG, El
Enclosures: PCN, Construction Document, Landowner Authorization Form, Check for permitting
CC: Ron Linville
2 0 1 1 0 3 6 9
o??F wiiaFRQ?v
t > LJ?J?7?
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.0 November 200
Pre-Construction Notification (PCN) Form
A. Applicant Information
JR L-1
1. Processing
1a. Type(s) of approval sought from the
Corps:
®Section 404 Permit El Section 10 Permit
1b. Specify Nationwide Permit (NWP) number. 27 or General Permit (GP) number: 3689
1c. Has the NWP or GP number been verified by the Corps? ? Yes ® No
1d. Type(s) of approval sought from the DWQ (check all that apply):
® 401 Water Quality Certification - Regular ? Non-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express ? Riparian Buffer Authorization
le. Is this notification solely for the record
because written approval is not required? For the record only for DWQ 401
Certification:
? Yes ® No For the record only for Corps Permit:

? Yes ® No
If Is payment into a mitigation bank or in-lieu fee program proposed for mitigation
of impacts? If so, attach the acceptance letter from mitigation bank or in-lieu
fee program. ? Yes ® No
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ? Yes ® No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes ® No
2. Project Information
2a. Name of project: Bog Turtle Stream Enhancement Project
2b. County: Surry
2c. Nearest municipality / town: Bryan p [5 (a w w [5 nn
2d. Subdivision name: N/A
2e. NCDOT only, T.I.P. or state
project no: N/A `?? 7011
3. Owner Information o':Nh- VYHIb' "UAL:
Svc ri ?aC AND, T R.
3a. Name on Recorded Deed: Florentino Family Trust
3b. Deed Book and Page No. DB 1262 Page 878
3c. Responsible Party (for LLC if
applicable): N/A
3d. Street address: 8490 Southwest 53?d RD CT
3e. City, state, zip: Miami, FL 33143
3f. Telephone no.: 336-366-2340
3g. Fax no.: N/A
3h. Email address: [e-mail]
Page 1 of 11
PCN Form - Version 1.0 November 2008 Version
Section A. Applicant Information, continued
4. Applicant Information (if different from owner)
4a. Applicant is: ® Agent ? Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name: Joshua White
5b. Business name
(if applicable): Michael Baker Engineering, Inc.
5c. Street address: 8000 Regency Parkway Suite 200
5d. City, state, zip: Cary, NC, 27518
5e. Telephone no.: 919-463-5488
5f. Fax no. 919-463-5490
5g. Email address: [e-mail]
Page 2 of 11
PCN Form - November 2008 Version
B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): 4957-00-08-1930
1b. Site coordinates (in decimal degrees): 36.4241`N - 80.8640`W
1c. Property size: 162.70 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to Mitchell River
proposed project:
2b. Water Quality Classification of nearest receiving water: C; TR, ORW
2c. River basin: Yadkin- Pee Dee
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
The Bog Turtle Enhancement Project is in an unstable section of the Mitchell River with areas of severe bank erosion.
This section of the Michell River also lacks fish habitat. It is located in a rural, agriculture based area with a narrow
riparian buffer and open fields on the south side and River Road on the north side.
3b. List the total estimated acreage of all existing wetlands on the property:
2.5 Acres
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3,700 LF
3d. Explain the purpose of the proposed project:
To enhance and stablize the stream and improve habitat by use of natural channel design structures and native
supplemental planting.
3e. Describe the overall project in detail, including the type of equipment to be used:
The stream enhancement project consist of approximately 2,800 linear feet of the Mitchell River. Enhancement consist of
instream stuctures, bank sloping, planting and transplants to stabilize banks and improve habitat. Work will be done with
tracked excavator with hydraulic thumb, track loader, and dump trucks.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property / ? Yes ® No ? unknown
project (including all prior phases) in the past?
4b. If the Corps made the jurisdictional determination, what type ? preliminary ? Final
of determination was made?
4c. If yes, who delineated the jurisdictional areas? Agency/Consultant Company:
Name (if known): Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifications been requested or obtained for ? Yes ® No ? Unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project? ? Yes ® No
6b. If yes, explain.
Page 3 of 11
PCN Form - Version 1.0 November 2008 Version
C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
? Wetlands ® Streams - tributaries ? Buffers
? Open Waters ? Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a. 2b. 2c. 2d. 2e. 2f.
Wetland impact
number --
Type of
Type of wetland
Forested Type of jurisdiction
(Corps - 404,
Area of impact (acres)
Permanent (P) or impact (if known) DWQ - non-404, other)
Temporary T
W1 ? P ? T ? Yes ? No ? Corps
? DWQ
W2 ? P ? T ? Yes ? No ? Corps
? DWQ
W3 ? PEI T ? Yes ? No ? Corps
? DWQ
W4 ? P ? T ? Yes ? No ? Corps
? DWQ
W5 [] p ? T ? Yes ? No ? Corps
? DWQ
W6 ? PEI T ? Yes ? No ? Corps
? DWQ
2g. Total wetland impacts
2h. Comments:
3. Stream Impacts
if there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a. 3b. 3c. 3d. 3e. 3f.
Stream impact Type of Stream name Perennial (PER) or Average stream width (feet) Impact
length
number - impact intermittent (INT)?
(linear feet)
Permanent (P) or
Temporary (T)
S1 ®P ? T Enhance Mitchell River ® PER ? INT 45 2,800
ment
S2 ? P ? T ? PER ? INT
S3 ? P ? T ? PER ? INT
S4 ? P ? T ? PER ? INT
S5 ? P ? T ? PER ? INT
S6 ? P ? T ? PER ? INT
3g. Total stream and tributary impacts 2,800
3h. Comments:
Page 4 of 11
PCN Form -- Version 1.0 November 2008 Version
C. Proposed Impacts Inventory, continued
4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individual) list all o en water impacts below.
4a. 4b. 4c. 4d. 4e.
Open water Name of
impact number waterbody Type of impact Waterbody type Area of impact (acres)
- Permanent (if
(P) or applicable)
Temporary (T)
01 ?P?T
02 ?P?T
03 ?P?T
04 ?P?T
4f. Total open water Impacts
4g. Comments:
Page 5 of 11
PCN Form -- November 2008 Version
C. Proposed Impacts Inventory, continued
6. Pond or Lake Construction
If and or lake construction pro osed then complete the chart below.
5a. 5b. 5c. 5d. 5e.
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID Proposed use or (acres)
number purpose of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
5f. Total
5g. Comments:
5h. Is a dam high hazard permit required?
? Yes ? No if yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If an impacts require mitigation, then ou MUST fill out Section D of this form.
6a.
? Neuse ?Tar-Pamlico ? Other:
Project is in which protected basin? ? Catawba ? Randleman
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number - Reason Buffer Zone 1 impact (square Zone 2 impact
Permanent (P) for impact Stream name mitigation feet) (square feet)
or Temporary required?
T
B1 ?P?T ?Yes ?No
B2 ? P ? T ? Yes ? No
B3 ?P?T ?Yes ?No
6h. Total buffer impacts
6i. Comments:
Page 6 of 11
PCN Form - November 2008 Version
D. Impact Justification and Mitigation
11. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Proposed impacts are required to enhance stream functions, fish habitat and bank stablility. Project will result in
enhancing approximately 2,800 linear feet (LF) of stream along the Mitchell River.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Contractor will disturb as little area as possible. Little clearing will be required. Any paths or haul roads created during
construction will be repaired upon completion of work. Contractor will work in the dry wherever possible. Construction
managers will adhere to the erosion control plan, utilizing silt fence.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State? ? Yes ® No
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps

2c. If yes, which mitigation option will be used for this
project? ? Mitigation bank
? payment to in-lieu fee program
? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type Quantity
3c. Comments:
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: warm, cool, cold
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h.. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 7 of 11
PCN Form -- Version 1.0 November 2008 Version
D. Impact Justification and Mitigation, continued
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation? ? Yes ® No
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
Zone Reason for impact Total impact
(square feet) Multiplier Required mitigation
(square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1.5
Total buffer mitigation required:
6c. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
6d. Comments:
Page 8 of 11
PCN Form - November 2008 Version
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified ? Yes No
within one of the NC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? ? Yes ? No
2. Determination If the Project Requires a Stormwater Management Plan
2a. Does the project require a Non-404 Jurisdictional General Permit? ? Yes ® No
2b. Is the project subject to General Certification 3704 or 3705? ? Yes ® No
3. Determination of Stormwater Review Jurisdiction
3a. Is this project subject to any of the following state-implemented stormwater ? Coastal counties
management programs (check all that apply)? ? HQW

If so, attach one copy of the approval letter from the DWQ and one copy of the ? ORW
? Session Law 2006-246
approved stormwater management plan. ? Other:
3b. In which local government's jurisdiction is this project? Surry County
3c. is this local government certified to implement a state stormwater program? ? Yes ? No
If so, attach one copy of the approval letter from the local government and one copy
of the approved stormwater management plan (or one copy of the approved
Stormwater management plan stamped as approved).
4. Information Required for DWQ 401 Unit Stormwater Review
4a. What is the overall percent imperviousness according to the most current site plan? <5%
4b. Does this project contain any areas that meet the criteria for "high density" per ? Yes ®No
General Certifications 3704 and 3705?
4c. If the site is over 24% impervious and/or contains high density areas, then provide a brief narrative description of the
stormwater management plan.
4d. Has a completed BMP Supplement Form with all required items been submitted ? Yes ? No
for each stormwater BMP?
Page 9of11
PCN Form - Version 1.0 November 2008 Version
E. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
la. Does the project involve an expenditure of public (federal/state/local) funds or the ® Yes ? No
use of public (federal/state) land?
1b. If you answered "yes" to the above, does the project require preparation of an
® Y
? No
environmental document pursuant to the requirements of the National or State es
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.)
Comments: NRCS funded stream restoration projects are categorically excluded
from the need to develop an Environmental Assessment. NRCS funded projects
? Yes
® No
are not however exempt from clompliance with the National Historical Preservation
Act and the Endangered Species Act. Permits for a recent wetland restoration
project on the same property were applied for and granted (DWQ# 09-1118 and
Action ID 200902089) . Attached to this permit application are letters that were sent
from the NCWRC, NC Department of Cultural Resources State Historic
Preservation Office for the wetland restoration project.
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ? Yes ® No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the-fact permit application? ? Yes ® No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in ? Yes ® No
additional development, which could impact nearby downstream water quality?
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
Page 10 of 11
PCN Form -- Version 1.0 November 2008 Version
F. Supplementary Information, continued
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or ® Yes ? No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act ® Yes ? No
impacts?

5c. If yes, indicate the USFWS Field Office you have contacted. ?
Raleigh
® Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
NCWRC Natural Heritage website, Natural Heritage workroom, USFWS
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ® Yes ? No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
USFWS, DWQ Waterbodies
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation ? Yes ® No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
North Carolina Office of Archives and History website was serched. A letter was also sent to the NC Office of State
Archaeology and the NC Historic Preservation Office for the above mentioned wetland restoration project on the same
site. The letter of response is attached.
8. Flood'Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? ® Yes ? No
8b. If yes, explain how project meets FEMA requirements: The enhancements will not cause an increase in the flood levels
and no fill will be deposited in the floodplain. We have discussed this with the Surry Co. Floodplain Manger.
8c. What source(s) did you use to make the floodplain determination? North Carolina Floodplain Mapping Information System

Applicant/Agent's Printed Name Applicant/Agent's Signature
(Agent's signature is valid only if an authorization letter from the applicant Date
is provided.)
Page 11 of 11
PCN Form - November 2008 Version
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89 _ Bog Turtle Farm Site
Surry County, NC
soy 52 1? 0 0.5 1
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North Carolina Wildlife Resources Commission 0
Gordon Myers, Executive Director
October 14, 2009
Mr. Ken Gillard
Michael Baker Engineering, Inc.
8000 Regency Parkway, Suite 200
Cary, North Carolina 27518
RE: Bog Turtle Farm Wetland Enhancement Project, Surry County
Dear Mr. Lanier:
This correspondence is in response to your letter of October 9, 2009 requesting site
determinations. Biologists with the North Carolina Wildlife Resources Commission (NCWRC)
are familiar with habitat values in the area. The. NCWRC is authorized to comment and make
recommendations which relate to the impacts of this project on fish and wildlife pursuant to
pursuant to the Clean Water Act of 1977, North Carolina Environmental Policy Act, US National
Environmental Policy Act, Endangered Species Act (16 U. S. C. 1531-1543; 87 Stat 884), and
Fish and Wildlife.Coordination Act (48 Stat. 401, as amended.
Based on our previous discussion with Dick Everhart concerning this site and our review of your
correspondence, we have the following comments and suggestions for the Bog turtle project:
Since the Bog turtle, Glyptemys inuhlenbergii (NCT, FT S/A) is known from the basin,
individuals working on the project should be given basic training concerning Bog turtle
identification. If a Bog turtle is observed during the project, the animal should be
removed from danger, properly identified (if previously marked) and relocated to an
adjacent and safe wetland area. If the Bog turtle has not been marked, it should be
marked by a Project Bog Turtle trained individual using standards methods developed for
identification purposes within the State of North Carolina and relocated to an adjacent
and safe wetland area.
o As trout are not indicated nearby, it is unlikely that a trout moratorium will be required
for the project; however, we will qumry our trout biologists further upon receipt of a
complete 404/401 permit/certification package.
Mailing Address: Division of Inland Fisheries • 1721 Mail Service Center • Raleigh, NC 27699-1721
Telephone: [phone] • Fax: [phone]
Bog Turtle 1Vettand Enhancement Page 2
October 14, 2009
For the long-term benefit of Bog turtle habitats, ongoing management of the wetland site
is critical as Bog turtles survive best where root mass does not interfere with burrowing
in wetlands or associated muddy soils. The site should be periodically disturbed by
allowing heavy (weight) livestock grassing, controlled burning or other prescribed
control methods on a pre-established schedule within the wetland. This should probably
occur on an annual or semi-annual basis. Management disturbances should occur during
a time when individual turtles and the turtle population are not likely to be harmed.
Accordingly, the method and timing of site disturbances should be determined by
professional herpetologists involved with Project Bog Turtle.
Thank you for the opportunity to comment on this project during its early planning stages. If you
have any questions regarding these comments, please contact me at 336-769-9453.
Sincerely,
4Ron Linville
Regional Coordinator
Habitat Conservation Program
.?+. StAYE Q,.

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North Carolina Department of Cultural Resources
State Historic Preservation Office
Peter B. Sandbeclr, Administrator
Beverly Eaves Perdue, Governor
Linda A. Carlisle, Secretary
Jeffrey J. Crow, Deputy Secretary
November 23, 2009
Ken Gilland
Michael Baker Engineering, Inc.
8000 Regency Parkway
Suite 200
Cary, NC 27518
Re: Bog Turtle Farm Stream Restoration, Surry County, ER 09-2674
Dear Mr. Gilland:
Thank you for your letter of October 26, 2009, concerning the above project.
Office of Archives and History
Division of Historical Resources
David Brook, Director
We have conducted a review of the project and are aware of no historic resources which would be affected by
the project. Therefore, we have no comment on the project as proposed.
The above comments are made pursuant to Section 106 of the National Historic Preservation Act and the
Advisory Council on Historic Preservation's Regulations for Compliance with Section 106 codified at 36 CFR
Part 800.
Thank you for your cooperation and consideration. If you have questions concerning the above comment,
please contact Renee Gledhill-Earley, environmental review coordinator, at 919-807-6579. In all future
communication concerning this project, please cite the above-referenced tracking number.
Sincerely,
2_'-QQ--
ter Sandbeck

Location: 109 East Jones Street, Raleigh NC 27601 Mailing Address: 4617 Mail Service Center, Raleigh NC 27699-4617 Telephone/Fax: [phone]-6599
AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO.

PLAN NO. PARCEL ID: 4957-00-08-1930
STREET ADDRESS: 1315 River Road
Dobson, NC 27017
Please print
y Owner: Fiorentino Family Trust
Propert
C/O Patrick Fiorentino
The undersigned, registered property owners of the above noted property, do hereby authorize
Kevin Tweedy, PE Michael Baker Engineering, Inc.
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all acdons necessary for the processing, Issuance and acceptance of
this permit or certification and any and all standard and spedal conditions attached.
Property Owner's Address (if different than property above):
8490 Southwest 53rd Court, Miami, Florida 33143
Telephone:
336-366-2340
We hereby certify the above information submitted In this application is true and accurate to the
best of our knowledge.
Authorized Signature
Date:

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