20231126 Duke Corrected agent form and info

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION: u
LOT NO. �_ PLAN NO, PARCEL ID: I ( Z -7 - J `-7'f
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STREET ADDRESS: 11Q Ncm¢_4 )CI (C w� lmoave 5v l jfL l� C 2g 11 J
Please prime
Property Owner:
The undersigned, regime property owners of the above noted property, do hereby authorize
err Lr�Sk of Lake 0 )Ymav-, Iyec iru
(Contractor / t) (Name of Ong firm) _1
r a. .i r •:.1 LIb r I - �Y. ..,.r • p"rl. M L�r .IY.•.>.
Property Owner's Add ress (W different than property above):
\1U VkcNu>.4sccLU Lin M60V'45VII[e
Telephone: 2-- n ` - 1 02z—
.>- . mo,..
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Auttrorizeel�irgnahue -
Date: `-7- 2.1 - 2- 2�

Full
Lake
puvwema/aommta.« Existing Dock
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.nawrt
�heot.nano�a/xn
h..150 h.
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•lrcfnury
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Flan View
FORM: SSGP 09-2020
Page 4 of 5

7. Will work
8. Total
9. Total amow
land -ward
conducted from land? ❑
of impacts below the normal pool lake
i water?I
/ Normal Water Level
ipacts (including all-yravation, backfill, ip rap, retaining walls, etc.) in squar-'
A n� 1.5 6 AWlr- uAC q ` o
yn �sy,iare f5ft _
�- _J
t of impacts above the normal pool lake I vel / Normal Water Level and 50 feet
Permanent 1 pacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet: / D/
QC�I��O��nl� �e `
Tem ora i C3� \ S
ry pacts (temporary clearing, construction corridor) in square feet:
10. Please descr )e the vegetation above the normal pool
felt Iandwa to be impacted (number of trees, for in.
11. Signature
level/ Normal Water Level and 50
nce):
By signing below, I, as the project proponent, certify tq the following:
• The prof 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
1-12!P��—
Owner/Agent's Signature' ( -,I Date
'Agent's signature is valid only if an authorization letter rom 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. Locatior of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d.
e.
of any proposed structures such as buildings, retaining walls, docks, etc.
of any excavation or dredging below the !!Full Pond/ Normal Water Level
FORM: SSGP 09-2020 1 Page 3 of 5