20150334 Ver 1_Landowner Authorization_20150406

WTL
V-CC(d
Landowner Authorization Form
I, the undersigned, a duly authorized owner of record of the property identified below, do hereby
authorize representatives of the Wilmington District, U S Army Corps of Engineers (Corps) to enter upon
the property herein described for a period, not to exceed 90 days from the date of this instrument, for the
purposes of conducting and/or approving the following action(s) associated with Waters of the U S
subject to Federal jurisdiction under Section 404 of the Clean Water Act and/or Section 10 of the Rivers
and Harbors Act of 1899
6 Jurisdictional determination and delineation of the boundaries of Waters of the U S
• Inspection and investigation of potential unauthorized activity(s)
• Inspection and evaluation of the property as a potential stream and /or wetland mitigation project
• Other (specify)
I further authorize Ms Keven Arrance of Hazen and Sawyer, P C to act and communicate on my behalf,
and to take all necessary steps to facilitate the above referenced actions to be conducted by representatives
of the Wilmington District, U S Army Corps of Engineers
Legal Description of Property See attached documentation.
County
Parcel ID Number
Owner of Record (please pnnt)
Parcel Street Address
Deed Book
Page #
This authorization also specifically includes the rights of ingress and egress on other adjoining lands
of the Owner not described above, provided such ingress and egress is necessary and not otherwise
conveniently available to the Corps.
I hereby certify the above information to be true and accurate to the best of my knowledge
Owner's Signatu e C ate
Owner's Signature Date
Owner(s) Address (if different from above)
Owner(s) Telephone Number 704 - 634 -8562
Version 5 2013
Charlotte Water
5100 Brookshire Blvd
Charlotte, NC 28216