20181054 Ver 1_Agent Authorization_20180731 (18)

AGENT AUTHORIZATION

This form authorizes Pilot to act as our agent in stream/wetland matters including U.S. Army
Corps of Engineers and North Carolina Division of Water Resources field ver ification and
permitting.

Property Address: ____________________________________
____________________________________
____________________________________
Owner Information:

Address: ______________________________________________________

______________________________________________________

______________________________________________________

Telephone Number: ______________________________________________________

Fax Number: ______________________________________________________

E-mail Address: ______________________________________________________

JURISDICTIONAL DETERMINATION REQUEST
D. PROPERTY ACCESS CERTIFICATION
By signing below, I authorize representatives of the Wilmington District, U.S. Army Corps of
Engineers (Corps) to enter upon the property herein described for the purpose of conducting on -
site investigations, if necessary, and issuing a jurisdictional determination pursuant to Section
404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors Act of 1899. I, the
undersigned, am either a duly authorized owner of record of the property identified herein, or
acting as the duly authorized agent of the owner of record of the property.

Print Name
Capacity: __ Owner __ Authorized Agent

Date

Signature