20220356 Ver 1_Agent Authorization_20220303

AGENT AUTHORIZATION FORM for US -ACE / NC-DWR Permitting
PROPERTY LEGAL DESCRIPTION: 81.75 acres J,G, and H,G. LEGGETT
LOT NO. PLAN NO. PARCEL ID: 5667-49-4140
STREET ADDRESS: _ 1140 Leggett Rd, Washington NC� _
Please print:
Property Owner 1: JENNIFER LEGGETT WHITEHURST
Property Owner 2: RUBY DIANE LEGGETT OWERRY
Property Owner 3: JAMES ALLEN LEGGETT
The undersigned, registered property owners of the above noted property, do hereby
authorize
_Gerald Pottern & Richard Mo eg nsen of _Mogensen Mitigation Inc (MMI)___
(Contractor / Agent) (Name of consulting firm)
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 (if different than property above):
3513 River Rd Washington NC 27889
Telephone: [phone] Email:
[e-mail]...
We hereby certify the above information submitted in this application is true and
accurate to the best of our knowledge.

Authorized Signature 1
Jennifer Leggett Whitehurst
Print Name 1
Date .
Authorized Signature 3
James Allen Leggett
Print Name 3
Date 1 '
Authorized Signature 2
Ruby Diane Leggett O'Mer
Print Name 2
E
Date