20230749 Ver 1_More Info Received_20230718 (3)

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. — PLAN NO.
STREET ADDRESS:
Please print
Property Owner:
Property Owner:
PARCEL ID: fl I `3
7317 Webbs Chapel Cove Ct. Denver NC 28037
Brandon OBrien
The undersigned, registered property owners of the above noted property, do hereby authorize
y�`eYrU LUSL of Lo ko 06rmaten ly-eU � u
(Contractor / ent) (Name of consulting firm) J J
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):
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorize Signature
Authorized Signature
Date: 7-17-23 Date:

Full Pond/ Normal Water Level
Shoreline
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Cl�ar�r��
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Plan View
Full Pond/ Normal Water
Shoreline
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Plan View
Lake
(At Full Pond/ Normal Water Level)
Lake
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FORM: SSGP 09-2020
Page 4 of 5

Lake
(At Full Pond/ Normal Water Level)
Side View
10 ft. back
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SideViEW
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2 ft. additimal clearing
3 f[. below full pond water level 4 h. abrnx lull pond water leeel ,d wm�
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FORM: SSGP 09-2020
Page 5 of 5

7. Will work be conducted from land? ❑ From water?
8. Total amount of impacts below the normal pool lake level / Normal alter Level
Permanent i acts (including all e
Ii
Temporary impacts in square feet:
backfill, rip rap, retaining walls, etc.) in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
impacts (includ;�g back fill, excavation, rip rap, retaining walls, etc.) in square feet:
impacts (temporary clearing, construction corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50
feet landward to be impacted (number of trees, for instance): U�:) Sic li
11. Signature
By signing below, I, as the project proponent, certify to the following:
The project proponent hereby certifies that all information contained herein is true,
accurate, and complete to the best of my knowledge and belief
The project proponent hereby requests that the certifying authority review and take action
on this CWA 401 certification request within the applicable reasonable period of time
Owner/Agent's Signature [ i N( _ ij
Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level
elevation
FORM: SSGP 09-2020 Page 3 of 5