20231245 Ver 1_Jenkins_LOA_signed2_20230627

LANDOWNER AUTHORIZATION FORM
PROPERTY LEGAL DESCRITION:
Deed Book: 3486
Parcel ID Number
Street Address:
Page: 1784
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Property Owner (please print: Ul r sa -t J t,L ns
County: CC -A-Ve-A
Property Owner (please print): ,K -
The undersigned, registered property owner(s) of the above property, do hereby authorize
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(Contractor/Agent/Project Manager)' (Name of Contractor/Agent F rm/Agency)'
to take all actions necessary for the evaluation of the property as a potential stream, wetland and/or
riparian buffer mitigation project, including conducting stream and/or wetland determinations and
delineations, as well as issuance and acceptance of any required permit(s) or certification(s). I
agree to allow regulatory agencies, including the NC Division of Water Resources, to visit the
property as part of these environmental reviews. /
Property Own ,ers(s) Address: Parcel is landlocked, access from 1501 Dover Rd.
(if different from above) Cove City, NC 28523
Property Owner Telephone Number:
Property Owner Telephone Number: 41�
We hereby certify the above information to be true and accurate to the best of our knowledge.
a
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rly"Oviwne uthori%ed Signature) (Date)
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(Property Owner Authorize 'ignatur (Date)
'Name of full delivery staff member (full -deliveries) or DMS project manager (design -bid -build).
Name of company (full -deliveries) or DMS (design -bid -build).