20110718 Ver 1_401 Application_20110811

Strickland, Bev
From: Ariana Jeske [[e-mail]]
Sent: Wednesday, August 03, 2011 4:13 PM
To: Strickland, Bev
Cc: [e-mail]
Subject: UNC Hospitals Hillsborough Campus 1 of 5
Attachments: 2011-08-03 PCN Submittal Packet.pdf; Summit - Agent Authorization Form 8-2-11.pdf
Bev,
These are the digital version of the PCN application materials and plans for the UNC Hospitals Hillsborough Campus. I
have broken the attachments into several emails to maintain a 10 MB limit. Let me know if you're missing any of them.
Thanks,
Ariana
Ariana J. Jeske, PE
Project Engineer
Infrastructure Branch
Phone: [phone]
Fax: [phone]
SUMMIT
CONSULTING
EMOMEERI:NG * ARCHITECTURE a SURVEYING
Hillsborough, NC • Nashville, TN • Roanoke, VA
Engineering (Dreams into 1Reafity
www.summit-engineer.com
j.A Please consider the environment before printing.
SUMMIT
CONSULTING
ENGINEERING I ARCHITECTURE II SURVEYING
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504 Meadowland Drive • Hillsborough, NC 27278
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LETTER OF TRANSMITTAL
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? Copy of Letter ? Change Order 4
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LETTER OF TRANSMITTAL
DATE 3 ZQ?\ TPROJ. NO. 0 Y'4L
RE: PC (j
WE ARE SENDING YOU ? Attached ? Under Separate Cover ? Transmitted Via
? Prints ? Reproducible ? Specifications ? Shop Drawings
? Copy of Letter ? Change Order 'PC t? ?fcK? , 4 S, ?kuL6
COPIES DRAWING DATE DESCRIPTION
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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the
Corps:
®Section 404 Permit El Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 39 or General Permit (GP) number:
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
1 e. 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
1 g. 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: University of North Carolina Hospitals Hillsborough Campus
2b. County: Orange
2c. Nearest municipality / town: Hillsborough
2d. Subdivision name: N/A
2e. NCDOT only, T.I.P. or state
project no: N/A
3. Owner Information
3a. Name(s) on Recorded Deed: University of North Carolina Hospitals at Chapel Hill
3b. Deed Book and Page No. DB 4832 PG 301
3c. Responsible Party (for LLC if
applicable): Raymond Lafrenaye, VP
3d. Street address: Suite 319, Med School Wing E, 101 Manning Drive
3e. City, state, zip: Chapel Hill, NC 27514
3f. Telephone no.: [phone]
3g. Fax no.: [phone]
3h. Email address: [e-mail]
Page I of 11
PCN Form - Version 1.3 December 10, 2008 Version
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: Ariana Jeske, PE
5b. Business name
(if applicable): Summit Consulting - Engineering, Architecture and Surveying, PLLC
5c. Street address: 504 Meadowland Dr
5d. City, state, zip: Hillsborough, NC 27278
5e. Telephone no.: [phone]
5f. Fax no.: [phone]
5g. Email address: [e-mail]
Page 2 of 11
PCN Form - Version 1.3 December 10, 2008 Version
B. Project Information and Prior Project History
1. ---Property Identification ---_---------------------------
1a. Property identification no. (tax PIN or parcel ID): 98732-22-6789
1 b. Site coordinates (in decimal degrees): Latitude: 36.0387 Longitude: - 79.0814
(DD.DDDDDD) (-DD.DDDDDD)
1 c. Property size: 57.71 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to Unnamed Tributary to Cates Creek
proposed project:
2b. Water Quality Classification of nearest receiving water: C, NSW
2c. River basin: Neuse
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 proposed project is located on a 57.71 acre parcel in the mixed-use Watersone Development in Hillsborough.
Approximately 15 acres of the tract are considered Altered Lands as they have previously been used as staging,
stockpile, and work areas for the construction of Watersone Drive. The rest of the parcel is mature forest land on a high
ridge.
3b. List the total estimated acreage of all existing wetlands on the property:
0 acres
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
1,150 feet of intermittent stream
3d. Explain the purpose of the proposed project:
The proposed project is to build a UNC Hospital campus in Hillsborough with the three buildings, utility plant, equipment
yard, and associated infrastructure.
3e. Describe the overall project in detail, including the type of equipment to be used:
The project will be constructed with a phased approach. All grading and all stream impacts will be undertaken in Phase I.
Phase I includes the construction of two story Diagnostic and Treatment building, four story patient bed wing, clinic
building, central utily plant, and equipment yard. Total square footage of these proposed components is 341,192 sft (over
multiple stories). The proposed project will be constructed with convential methods. A retaining wall is proposed to
minimize overall impact associated with the roadway crossing. Additionally, a 10" DIP sanitary sewer will cross the
subject stream downstream from the roadway crossing at a perpendicular angle; impacts associated with the sanitary
sewer crossing are limted to buffer impacts as the sanitary sewer will bridge over the top of bank.
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?
Comments:
--------------------
-- - ---------- ----------- --
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: Orange County Erosion
Control Division
Name (if known): Terry Hackett Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
January 12, 2010
Page 3 of 11
PCN Form - Version 1.3 December 10, 2008 Version
--
5. ----------------------------------------------------------
Project History
5a. Have permits or certifications been requested or obtained for?
this project (including all prior phases) in the past? ? Yes- -- ®-No- --? Unknown
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
Phasing applies to building construction only. All grading and environmental impacts will occur in Phase I for the entire
project.
Page 4 of 11
PCN Form - Version 1.3 December 10, 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 Type of jurisdiction
number - Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ - non-404, other) (acres)
Temporar TT)
W1 ? P ? T ? Yes ? Corps
? No ? DWQ_
W2 ? P ? T ? Yes ? Corps
? No ? DWQ
W3 ? p ? T --- ---- ----- ? Yes ? Corps
? No ? DWQ _
W4 ? P ? T ? Yes ? Corps
? No ? DWQ
W5 ? P ? T ? Yes ? Corps
? No ? DWQ
W6 ? P ? T _
? Yes ? Corps
? No ? 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. 3g.
Stream impact Type of impact Stream name Perennial Type of jurisdiction Average Impact
number - (PER) or (Corps -404, 10 stream length
Permanent (P) or intermittent DWQ - non-404, width (linear
Temporary (T) (INT)? other) (feet) feet)

S1 ? P ? T
Fill Unnamed
Tributary to Cates ? PER

®INT ® Corps

?DWQ
6
27
Creek
_
S2 ® P ? T
Fill Unnamed
Tributary to Cates ? PER

®INT ® Corps

?DWQ
6
5
Creek -- -
S3 ? P ? T.._ -- - -- --- ? PER ? Corps
? INT ? DWQ
S4 ? P ? T ? PER ? Corps
? INT ? DWQ
S5 ? P ? T _ ? PER ? Corps
? INT ? DWQ
S6 ? P ? T _ ? PER ? Corps
? INT ? DWQ
3h. Total stream and tributary impacts 32
3i. Comments: Assumed permanent impact of 5 If associated with the sanitary sewer construction (S2).
Page 5 of 11
PCN Form - Version 1.3 December 10, 2008 Version
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 individually list all open water impacts below_
4a.
Open water
impact number
- Permanent (P)
or Temporary 4b.
Name of waterbody
(if applicable) 4c.

Type of impact 4d.

Waterbody type 4e.

Area of impact (acres)
01 ?P?T
-- -
02 ? P ? T ----- - -- -
03 ? P ? T ----- -
04 ? P ? T - -----
4L Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed, then complete the chart below.
5a.

Pond ID 5b.

Proposed use or purpose of 5c.
Wetland Impacts (acres) 5d.
Stream Impacts (feet) 5e.
Upland
(acres)
number pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1 [ _
P2 - -- ---
_
5L 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):
L53kMbKhod of construction:
Page 6 of 11
PCN Form - Version 1.3 December 10, 2008 Version
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 any impacts require mitigation, then you 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 for Buffer Zone 1 impact Zone 2 impact
Permanent (P) impact Stream name mitigation (square feet) (square feet)
or Temporary required?
T _

B1 ®P ? T Roadway Unnamed Tributary to Cates ? Yes
253
2
3,131
Crossing Creek ® No ,
B2 ? P ® T Roadway Unnamed Tributary to Cates ? Yes 900
Crossing Creek ® No

B3 ® P ® T Nonelectric
Utility Unnamed Tributary to Cates ? Yes
900
600
Crossing Creek ® No
_
6h. Total buffer impacts 4,353 3,931
6i. Comments: See attached sheet for complete buffer impacts. 5' wide crossing assumed for permanent impacts, 20' (minus
5' for permanent) assumed for temporary impacts (limited to clearing). Buffer impacts B1 and B2 are exempt under the
threshold of 40 linear feet of buffer impact.
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
A retaining wall be used on the road crossing at the stream and buffer areas minimize overall impacts. The roadway crossing
associated with this impact is on driveway into the hospital parking area. The driveway is located in such a way to create a
four legged interesection with existing Waterstone Drive and an existing driveway. Relocation of the driveway will result in an
less desirable offset intersection. Sanitary sewer will cross the stream perpendicularly to minimize all impacts and above the
top of bank to minimize fill in the stream.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
A fulll erosion control plan from NCDENR Division of Land Quality has been approved for this project and will be strictly
followed. Construction will be restricted to the permitted impact areas only and stay out of adjacent stream and buffer areas.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for ? Yes ® No
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps
? Mitigation bank
2c. If yes, which mitigation option will be used for this project? ? 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
Page 7 of 11
PCN Form -Version 1.3 December 10, 2008 Version
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.
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 6c.
Reason for impact 6d.
Total impact
(square feet)
Multiplier 6e.
Required mitigation
(square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1.5
6f. Total buffer mitigation required:
6g. 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).
6h. Comments:
Page 8 of 11
PCN Form - Version 1.3 December 10, 2008 Version
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified ® Yes ? No
within one of the NC Riparian Buffer Protection Rules?
1b. If yes, then is a diffuse flow plan included? If no, explain why.
® Yes ? No
Comments:
2. Stormwater Management Plan

2a. What is the overall percent imperviousness of this project? 37.3%
2b. Does this project require a Stormwater Management Plan? ® Yes ? No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
Town of Hillsborough NPDES Phase II and Nutrient Sensitive Waters requirements are met by the proposed Stormwater
Management Plan. (SW MP) The SW MP attenuates and treats the difference between the predevelopment and post
development 1 yr, 24 hour storm through use of on site BMPs including a wet/extend ed dry detention pond and
bioretention basin. Neuse River nitrogen requirements will be met through a combina tion of onsite treatment and buy
down credits.
® Certified Local Government
2e. Who will be responsible for the review of the Stormwater Management Plan? ? DWQ Stormwater Program
? DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project? Hillsborough
® Phase ??
® NSW
3b. Which of the following locally-implemented stormwater management programs ? USMP
apply (check all that apply): ? Water Supply Watershed
? Other:
3c. Has the approved Stormwater Management Plan with proof of approval been ® Yes ? No
attached?
4. DWQ Stormwater Program Review
? Coastal counties
? HQW
4a. Which of the following state-implemented stormwater management programs apply ? ORW
(check all that apply): ? Session Law 2006-246
? Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
? Yes ? No
attached?
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? ? Yes ? No
5b. Have all of the 401 Unit submittal requirements been met? ? Yes ? No
Page 9 of 11
PCN Form - Version 1.3 December 10, 2008 Version
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the ? Yes ® No
use of public (federal/state) land?
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State ? Yes ? No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c. 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
? Yes ? No
letter.)
Comments:
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.
All wastewater will be collected via an onsite collection system for transfer to the Town of Hillsborough wastewater
system.
Page 10 of 11
PCN Form - Version 1.3 December 10, 2008 Version
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?
? Raleigh
5c. If yes, indicate the USFWS Field Office you have contacted.
? Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
USFWS Threatened and Endangered Species list by County and Natural Heritage Program Website
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?
USACE recommended website, South Atlantic Habitat and Ecosystem IMS
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?
NC State Historic Preservation Office GIS Website
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:
8c. What source(s) did you use to make the floodplain determination?

Ariana J Jeske
Applicant/Agent's Printed Name Applicant/A n s i ature Date
(Agent's signature is valid only if a th ri ion letter from the applicant
is provided.
Page 11 of 11
PCN Form - Version 1.3 December 10, 2008 Version
UNC Hospitals Hillsboroueh Camous PCN Additional Sheet No. 1
6b. Buff impact
number - 6f. Zone 1 6g. Zone 2
Permanent (P) 6e. Buffer impact impact
or Temporary 6c. Reason for Mitigation (square (square
(T) Impact 6d. Stream Name Required? feet) feet)
Roadway Unnamed Tributary to Cates
B1 P Crossing Creek No 2,253 3,131
Roadway Unnamed Tributary to Cates
B2 T Crossing Creek No 900
Noneletric Utility Unnamed Tributary to Cates
B3 P Crossing Creek No 300 200
Noneletric Utility Unnamed Tributary to Cates
B4 T Crossing Creek No 900 600
6h. Tota l buffer impacts 4,353 3,931
ORANGE COUNTY PLANNING & INSPECTIONS DEPARTMENT
Craig N. Benedict, AICP, Director
Administration 245-2575
antr o/ Or
Erosion Control Division a,- 306F Revere Road
[phone] P O Box 8181
[phone] (FAx)Hillsborough, NC 27278
e.nc.us ° rry ?a o°
www.co.oranc

NNW
January 12, 2010
John Collins
1000 Corporate Drive
Suite 101
Hillsborough, NC 27278
Re: Neuse Buffer & Town of Hillsborough Surface Water Identification
Lower Eno Unprotected Watershed
PIN: 9873-22-6489, TMBL: 4.45..2N
To Whom It May Concern:
This letter serves as confirmation of an on-site stream determination made by Orange
County Erosion Control Division staff on January 7, 2010 for the referenced property.
Orange County is the local delegated authority for enforcing the Neuse Buffer Rules
(Neuse River Basin: Nutrient Sensitive Waters Management Strategy Protection and
Maintenance of Riparian Areas Rule (15A NCAC 2B. 0233)).
In addition, Orange County Erosion Control Division conducts stream determinations
pursuant to the Town of Hillsborough's stream buffer regulations. The Town of
Hillsborough enforces a buffer along streams and water features per the Town's Zoning
Ordinance (see Section 7.1 Stream Buffers). This even includes previously unmapped
streams or water features if they are determined to exist during the field determination.
Our field visit to the parcel in question determined that the following water features will /
may affect the property:
1. Feature A, a previously unmapped stream segment, is present in the field and
therefore subject to buffer regulations. The beginning point has been flagged in the
field for reference.
S:\\ErosionControlDivision\2010\Neuse\011210.TMBL4.45..2N.UNC
2
2. Feature B, a previously mapped stream segment, is present in the field and therefore
subject to buffer regulations.
3. Feature B-1, a previously mapped stream segment, is present in the field and
therefore subject to buffer regulations. The subject segment was shortened on the
parcel in question, so the new beginning point has been flagged in the field for
reference.
4. Feature B-2, a previously unmapped stream segment on the adjacent parcel, is
present in the field and therefore subject to buffer regulations. The beginning point is
just outside the property line for the parcel in question, so it has been flagged in the
field for reference in case the buffer does overlap.
If you have questions about this determination, please contact me at [phone].
Sincerely,
Wesley Poole
Erosion Control Officer I
Attachments: Aerial Photograph / Map
cc: File
S:\\ErosionControl Division\2010\Neuse\011210.TMBL4.45..2N.UNC

USGS Water Feature
O Parcel
Zoning
Q 100 YR Floodplain (Effective 02/02/07) 0 220 440
Feet
?.?+ Soils Survey Water Feature Township City Limits Floodway (Effective 02/02107) 1 inch = 400 feet
likIN& OC Updated Water Feature School System Boundary r ,.r' EfJ - 500 Year Floodplains (Effectve 02102/07)
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Agent Authorization Form
Property Legal Description
Parcel ID: 98732-22-6789
Location:
Waterstone Drive Between NC 86 and Old 86, Hillsborough, NC
Property Owner:
University of North Carolina Hospitals at Chapel Hill
The undersigned, representatives for the property owner of the above note property, do
hereby authorize Ariana Jeske, PE of Summit Consulting - Engineering, Architecture and
Surveying, PLLC to act on my behalf and take all actions necessary for the processing,
issuance and acceptance of this permit or certification and any and all standard and
special conditions attached.
Property Owner's Address:
Suite 319, Medical School Wing E, CB7600
101 Manning Drive
Chapel Hill, NC 27514
Telephone: [phone]
We hereb certify the above information submitted in this application is true and accurate
to - eft of o ledge.
Raymond R. ?afrenaye
Authorized Signature
Date