20140574 Ver 5_Agent Authorization 020119_20190318

Mitchell Environmental, P.A.
The Department of the Army
US Army Corps of Engineers
Wilmington District
PO Box 1890
Wilmington, NC 28402-1890
To Whom It May Concern:
AGENT AUTHORIZATION and
PROPERTY OWNER CERTIFICATION FORM
All Blanks to be Filled in by Current Landowner
NCDENR - Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
I, the undersigned, current property owner designate and authorize representatives of Mitchell Environmental,
P.A., to act on my behalf as my agent in the processing of permit applications, to furnish upon request
supplemental information in support of applications, etc., from this day forward.
This the [ day of f�iiSay-4U, 20jc
(number) (Month) (Year)
I, the undersigned, a duly authorized owner of record of the property/properties identified herein, do 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 and issuing a determination associated
with Waters of the U.S. subject to Federal jurisdiction under Section 404 of the Clean Water Act and/or Section
10 of the Rivers and Harbors Act of 1899.
This notification supersedes any previous correspondence concerning the agent for this project.
Project Name: Sy*YLr f i3Ly�� 044�C [ 7 Location: t fCM047*4%" RO�� T tl&& IlAIZIWI�
Property Owner's Name (Print): 7 /V Gi G� %cif/: 044-0 6L *-MOS/
Property Owner's Signature:
Property Owner's Mailing Address: Ro Po Y, �jg
Property Owner's Telephone: 7/7--53?- (--57%' 36 37C Fax No.
Property Owner's Email Address:
1501 Lakestone Village Lane, Suite 205
Fuquay-Varina, North Carolina 27526
919-669-0329
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