20230894 Ver 1_Signed Agent Authorization_20230620

7 Samuel Ashe Drive, Asheville, NC 28805 1 919-600-4790 1 [e-mail]
AGENT AUTHORIZATION FORM
Project Name: Surry County SCC Watershed Sites
Project Address/Location: 5 sites see attached table
The undersigned is the
n
Property Owner Assigned
�Vl/ Representative
a Easement
Holder
Right -Of-
D Way Holder
Lease Holder
E
and will be the applicant on the request for permit(s) and/or jurisdictional determination. I
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. I
hereby certify that the information submitted in this document is true and accurate to the best
of our knowledge.
Name:
Company Name
(if applicable):
Mailing Address:
Phone Number:
Email Address:
Signature:
Date:
Chris Knopf, County Manager
336-401-8201
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
Course Stream Restoration
Cedarbrook Country Club
495303337074
225 Country Club Drive
36.30675,
-80.85366
Site 3: Big Elkin Creek —
William & Cicely Roth
495118312993
137 Terrace Avenue
3G.24
36.24 18
318
Front Street
Rosa & Caroline Beverley
495118229381
122 Terrace Avenue
94
To & Elena Thomasson
495118229403
112 Terrace Avenue
Parking area at NE
Site 4: Big Elkin Creek —
Town of Elkin
495113233350
corner of Memorial
36.24534
City Park
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.