20230808 Ver 1_Signed Agent Authorization_20230606

Environmental
7 Samuel Ashe Drive,Asheville, NC 28805 1 919-600-4790 1 [e-mail]
AGENT AUTHORIZATION FORM
Project Name: Surry County C Watershed Sites
Project Address/Location: 5 sites see attached table
The undersigned is the
ki
Assigned Easement D Right-Of- Lease Holder
Property Owner Representative Holder Way Holder
and will be the applicant on the request for permit(s) and/or jurisdictional determination.
hereby authorize Jennings Environmental PLLC to act on my behalf and take all actions
necessary for the processing, issuance, and acceptance of the permit or certification and any
and all standard and special conditions attached. Additionally, I authorize the representative(s)
of the permitting agency(s) to enter the property for the purpose of conducting activities
associated with verification of the request for permit(s) and/or jurisdictional determination.
hereby certify that the information submitted in this document is true and accurate to the best
of our knowledge.
Name: Chris Knopf, County Manager
Company Name
(if applicable): Surry County
Mailing Address: P.O. Box 1467
Dobson. NC 27017
Phone Number: 336-401-8201
Email Address: kno ffcc )co surry nc us
Signature:
Date: 05/02/2023
Check if applicable
The property owner has executed a binding agreement with the Natural Resources Conservation
Service (NRCS)for this stream/wetland restoration project. The above is the assigned representative
for the NRCS and is authorized to act on behalf of the NRCS and the property owner through a signed
mutual agreement for the stream sabilization/restoration project.
Jennings Environmental PLLC is licensed with the North Carolina Board of Examiners for Engineers and Surveyors and is
authorized to practice engineering under the provisions of Chapter 89C and 55B of the General Statutes of North Carolina.
License Number P-1932.

Surry County SCC Watershed Sites 2023
Site Name Owners Parcel ID No. Location Lat./Long.
Site 1: Community College Surry Community College 495303237606 Between Klondike Rd. 36.30366,
Gull &US Hwy 21, -80.85787
Site 2: Camp Creek Golf Cedarbrook Country Club 495303337074 225 Country Club Drive 36.30675,
Course Stream Restoration -80.85366
Site 3:Big Elkin Creek— William&Cicely Roth 495118312993 137 Terrace Avenue 36.24318
Front Street Rosa&Caroline Beverley 495118229381 122 Terrace Avenue -80.85394
Toy&Elena Thomasson 495118229403 112 Terrace Avenue
Parking area at NE
Site 4:Big Elkin Creek— corner of Memorial 36.24534
City Park Town of Elkin 495113233350 Park Dr. &Elk Spur -80.85701
Street
Site 5: South Fork Mitchell Phillip &Kara Raley 495500523018 East of bridge over S. 36.35299,
River Phillip&Phyllis Harris 495500407758 Fork Mitchell River on -80.85074
Mountain Park Rd.