20191123 Ver 1_LandownerForms_20190822

Jurisdictional Determination Request
A. PARCEL INFORMATION
Street Address: 0 West Inness Street
City, State: Salisbury, NC
County: Rowan
Parcel Index Number(s) (PIN): #326-254
B. REQUESTOR INFORMATION
Name: David Perry - WK Dickson
Mailing Address: 616 COlonade Dr
Charlotte, NC 28205
Telephone Number:
704-227-3408
Electronic Mail Address: [e-mail]
Select one:
1-1 I am the current property owner.
❑� I am an Authorized Agent or Environmental Consultants
1-1 Interested Buyer or Under Contract to Purchase
Other, please explain.
C. PROPERTY OWNER INFORMATION'
Name: Catawba College Trustee
Mailing Address:
Telephone Number:
Electronic Mail Address:
2300 W Inness St
Salisbury, NC 28144
' Must provide completed Agent Authorization Form/Letter.
2 Documentation of ownership also needs to be provided with request (copy of Deed, County GIS/Parcel/Tax Record).
Version: May 2017 Page 2

Jurisdictional Determination Request
D. PROPERTY ACCESS CERTIFICATION' 4
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:
0 Owner IJAuthorizedAgent' C�/(��S�D(wr>
Date .�
E. REASON FOR JD REQUEST: (Check as many as applicable)
❑ I intend to construct/develop a project or perform activities on this parcel which would be
designed to avoid all aquatic resources.
❑ I intend to construct/develop a project or perform activities on this parcel which would be
designed to avoid al ljurisdictional aquatic resources under Corps authority.
❑ I intend to construct/clevelop a project or perform activities on this parcel which may
require authorization from the Corps, and the JD would be used to avoid and minimize
impacts tojurisdictional aquatic resources and as an initial step in a future permitting
process.
nI intend to construct/develop a projector perform activities on this parcel which may
require authorization from the Corps; this request is accompanied by my permit application
and the JD is to be used in the permitting process.
❑ I intend to construct/develop a projector perform activities in a navigable water of the
U.S. which is included on the district Section 10 list and/or is subject to the ebb and flow of
the tide.
A Corps JD is required in order obtain my local/state authorization.
I intend to contest jurisdiction over a particular aquatic resource and request the Corps
confirm that jurisdiction does/does not exist over the aquatic resource on the parcel.
❑ I believe that the site may be comprised entirely of dry land.
❑ Other:
3 For NCDOT requests following the current NCDOTIUSACE protocols, skip to Part E.
If there are multiple parcels owned by different parties, please provide the following for each additional parcel on a
continuation sheet.
' Must provide agent authorization form/letter signed by owner(s).
Version: May 2017 Page 3

Jurisdictional Determination Request
A. PARCEL INFORMATION
Street Address: 2085 North Park Dr
City, State: Salisbury, NC
County: Rowan
Parcel Index Number(s) (PIN): #001-159
B. REQUESTOR INFORMATION
Name: David Perry - WK Dickson
Mailing Address: 616 Colonade Dr
Charlotte, NC 28205
Telephone Number: 704-227-3408
Electronic Mail Address: [e-mail]
Select one:
❑ I am the current property owner.
I am an Authorized Agent or Environmental Consultant'
Interested Buyer or Under Contract to Purchase
Other, please explain.
C. PROPERTY OWNER INFORMATION
Name: Catawba College Trustee
Mailing Address: 2300 W Inness St
Salisbury, NC 28144
Telephone Number:
Electronic Mail Address:
' Must provide completed Agent Authorization Form/Letter.
z Documentation of ownership also needs to be provided with request (copy of Deed, County G1S/Parcel/Tax Record).
Version: May 2017 Page 2

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 put -pose 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.
dz(5�1�
Print Name
Capacity: �❑ Owner �2�
Authorized Agents (,1L)( -T
—I —
Date
E. REASON FOR JD REQUEST: (Check as many as applicable)
❑ I intend to construct/develop a project or perform activities on this parcel which would be
designed to avoid all aquatic resources.
❑ I intend to construct/develop a project or perform activities on this parcel which would be
designed to avoid alliurisdictional aquatic resources under Corps authority.
I intend to construct/develop a project or perform activities on this parcel which may
require authorization from the Corps, and the JD would be used to avoid and minimize
impacts tojurisdictional aquatic resources and as an initial step in a future permitting
�)Cetis.
I intend to construct/develop a project or perform activities on this parcel which may
require authorization from the Corps; this request is accompanied by my permit application
and the JD is to be used in the permitting process.
I intend to construct/develop a projector perform activities in a navigable water of the
U.S. which is included on the district Section 10 list and/or is subject to the ebb and flow of
the tide.
A Corps JD is required in order obtain my local/state authorization.
I intend to contest jurisdiction over a particular aquatic resource and request the Corps
confirm that jurisdiction does/does not exist over the aquatic resource on the parcel.
I believe that the site may be comprised entirely of dry land.
Other:
t For NCDOT requests following the current NCDOT/USACE protocols, skip to Part E.
5 If there are multiple parcels owned by different parties, please provide the following for each additional parcel on a
continuation sheet.
s Must provide agent authorization form/letter signed by owner(s).
Version: May 2017 Page 3

Jurisdictional Determination Request
A. PARCEL INFORMATION
Street Address: 924 Statesville Blvd
City, State:
County:
Salisburv, NC
Rowan
Parcel Index Number(s) (PIN):
B. REQUESTOR INFORMATION
#332-021
Name:
David Perry - WK Dickson
Mailing Address:
616 Colonade Dr
Charlotte, NC 28205
Telephone Number:
704-227-3408
Electronic Mail Address:
[e-mail]
Select one:
❑ I am the current property owner.
❑ I am an Authorized Agent or Environmental Consultant'
7 Interested Buyer or Under Contract to Purchase
❑ Other, please explain.
C. PROPERTY OWNER INFORMATION'
Name:
Norman Sloop
Mailing Address:
1112 Statesville Blvd
Salisbury, NC 28144
Telephone Number:
- 1 (,LA ( ,- 7 � 3 L cl
Electronic Mail Address: t, Y r^ h S L� v vNf °l P � ct� � o c v"
Must provide completed Agent Authorization Form/Letter.
z Documentation of ownership also needs to be provided with request (copy of Deed, County GIS/Parcel/Tax Record).
Version: May 2017 Page 2

Jurisdictional Determination Request
D. PROPERTY ACCESS CERTIFICATIONs,4
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 ajurisdictional 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 Names El Capacity: ' Owner ❑ Authorized Agents
Date
1I c,
E. REASON FOR JD REQUEST: (Check as many as applicable)
❑ I intend to construct/develop a project or perform activities on this parcel which would be
designed to avoid all aquatic resources.
❑ I intend to construct/develop a project or perform activities on this parcel which would be
designed to avoid all jurisdictional aquatic resources under Corps authority.
❑ I intend to construct/develop a projector perform activities on this parcel which may
require authorization from the Corps, and the JD would be used to avoid and minimize
impacts to jurisdictional aquatic resources and as an initial step in a future permitting
process.
I intend to construct/develop a projector perform activities on this parcel which may
require authorization from the Corps; this request is accompanied by my permit application
and the JD is to be used in the permitting process.
❑ I intend to construct/develop a project or perform activities in a navigable water of the
U.S. which is included on the district Section 10 list and/or is subject to the ebb and flow of
the tide.
BA Corps JD is required in order obtain my local/state authorization.
I intend to contest jurisdiction over a particular aquatic resource and request the Corps
confirm that jurisdiction does/does not exist over the aquatic resource on the parcel.
HI believe that the site may be comprised entirely of dry land.
Other:
For NCDOT requests following the current NCDOT/USACE protocols, skip to Part E.
If there are multiple parcels owned by different parties, please provide the following for each additional parcel on a
continuation sheet.
5 Must provide agent authorization form/letter signed by owner(s).
Version: May 2017 Page 3

Jurisdictional Determination Request
A. PARCEL INFORMATION
Street Address: 0 Statesville Blvd
City, State: Salisbury, NC
County: Rowan
Parcel Index Ntunber(s) (PIN): #332-092
B. REQUESTOR INFORMATION
Natne: David Perry - WK Dickson
Mailing Address: 616 Colonade Dr
Telephone Number:
Charlotte, NC 28205
704-227-3408
Electronic Mail Address: [e-mail]
Select one:
I am the current property owner.
n✓ I am an Authorized Agent or Environmental Consullantl
❑ Interested Buyer or Under Contract to Purchase
Other, please explain.
C. PROPERTY OWNER INFORMATION'
Name: Land Trust for Central North Carolina
Mailing Address: 204 E Inness Street Suite 280
Salisbury, NC 28144
"TelephoncNumber:--
fElectronic Mail Address: �� — "a
-- -- — -
' Must provide completed Agent Authorization Fonnl—l.etter.—
' Documenlation of ocmtership also needs to be provided wilh request (cop) of Deed, County GIS/Parcel! ray Record).
Version: Ahq 2017 Page 2

Jurisdictional Determination Request
D. PROPERTY ACCESS CERTIFICATION11
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.
I (vim-g&Ff
Print Name
e Capacity: ❑ Owner Ek Authorized Agent'
1 --s-M- -
Date
Signature
E. REASON FOR JD REQUEST: (Check as many as applicable)
❑ I intend to construct/develop a project or perform activities on this parcel which would be
designed to avoid all aquatic resources.
❑ I intend to construct/develop a projector perform activities on this parcel which would be
designed to avoid alljtuisdictional aquatic resources under Corps authority.
❑ I intend to construct/develop a project or perform activities on this parcel which may
require authorization from the Corps, and the JD would be used to avoid and minimize
impacts tojurisdictional aquatic resources and as an initial step in a future permitting
process.
n I intend to construcUdevelop a project or perform activities on this parcel which may
require authorization from the Corps; this request is accompanied by my permit application
and the JD is to be used in the permitting process.
❑ l intend to consu•uct/develop a projector perform activities in a navigable water of the
U.S. which is included on the district Section 10 list and/or is subject to the ebb and now of
the tide.
eA Corps JD is required in order obtain my local/state authorization.
I intend to contestjurisdiction over a particular aquatic resource and request the Corps
confirm thatjurisdiction does/does not exist over the aquatic resource on the parcel.
Hl believe that the site may be comprised entirely of dry land.
Other:
' For NCDOT requests following the currant NCDOT/USAGE protocols, skip to Pan E.
' If there are multiple parcels owned by different parties, please provide the following for each additional parcel on a
continuation sheet.
` Must provide agent authorization fonNletter signed by owner(s).
Version: Alai 2017 Page 3

Jurisdictional Determination Request
A. PARCEL INFORMATION
Street Address: 0 East Colonial Dr
I
C.
City, State: Salisbury, NC
County: Rowan
Parcel Index Number(s) (PIN): #335-119
REQUESTOR INFORMATION
Name: David Perry - WK Dickson
Mailing Address:
Telephone Number:
616 Colonade Dr
Charlotte, NC 28205
704-227-3408
Electronic Mau Address: [e-mail]
Select one:
❑ I am the current property owner.
✓❑ I am an Authorized Agent or Environmental Consultant(
❑ Interested Buyer or Under Contract to Purchase
❑ Other, please explain.
PROPERTY OWNER INFORMATION'
Name: Land Trust for Central North Carolina
Mailing Address: 204 E Inness Street Suite 280
Salisbury, NC 28144
I Telephone Number: Za q - %' 662c'
Electronic Mail Address: _ S� i��l w/Ivy ors
J
\lust provide conrpIeled Agent Authorization ForndLetter.
' Documentation of ownership also needs to be provided with request (copy of Deed, Counly GIS/ParceVTax Record),
Version: Ahq 2017 Page 2

Jurisdictional Determination Request
D. PROPERTY ACCESS CERTIFICATION'-'
By signing below, I authorize representatives of the Wilmington District, U.S. Anny 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 Rivets and Harbors Act of 1899. 1, the
undersigned, am either a duly authorized owner of record of the property identified herein, or
acting as the duly authooriized_ agent of the owner of record of the property.
J'Capacity: ❑ Owner uthorized Agents
Date
Signatul e
E. REASON FOR JD REQUEST: (Check as many as applicable)
❑ 1 intend to construct/develop a project or perr'm•m activities on this parcel which would be
designed to avoid all aquatic resources.
I intend to construct/develop a project or perform activities on this parcel which would be
designed to avoid all jurisdictional aquatic resources under Corps authority.
I intend to construcUdevelop a projector perform activities on this parcel which may
require authorization from the Corps, and the JD would be used to avoid and minimize
impacts tojurisdictional aquatic resources and as an initial step in a future permitting
process.
❑ I intend to construct/develop a project or perform activities on this parcel which may
require authorization from the Corps; this request is accompanied by my permit application
and the JD is to be used in the permitting process.
❑ I intend to construct/develop a projector perform activities in a navigable water of the
U.S. which is included on the district Section 10 list and/or is subject to the ebb and Flow of
the tide.
®✓ A Corps JD is required in order obtain my local/stale authorization.
I intend to contest jurisdiction over a particular aquatic resource and request the Corps
confirm that jurisdiction does/does not exist over the aquatic resource on the parcel.
HI believe that the site may be comprised entirely of dry land.
Other:
' For NCDOT requests following the current NCDOT/USACE protocols, skip to Pon E.
If there are multiple parcels owned by different parties, please provide the following for each additional parcel on a
continuation sheet.
Must provide agent authorization fomrQetter signed by owner(s).
Version: \hq 2017 Page 3

Jurisdictional Determination Request
D. PROPERTY ACCESS CERTIFICATION'°a
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. 1, 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.
0Zl/-)-OQP 0r/*W0-)-9L-
Print Name
Q Capacity: ❑ Owner
e Z0
Date t
Q
Sign
Authorized Agent'
E. REASON FOR JD REQUEST: (Check as many as applicable)
❑ i intend to construct/develop a project or perform activities on this parcel which would be
designed to avoid all aquatic resources.
❑ i intend to construct/develop a project or perform activities on this parcel which would be
designed to avoid all jurisdictional aquatic resources under Corps authority.
❑ I intend to construct/develop a project or perform activities on this parcel which may
require authorization from the Corps, and the JD would be used to avoid and minimize
impacts to jurisdictional aquatic resources and as an initial step in a future permitting
process.
❑ I intend to construct/develop a project or perform activities on this parcel which may
require authorization from the Corps: this request is accompanied by my permit application
and the JD is to be used in the permitting process.
❑ I intend to construct/develop a project or perform activities in a navigable water of the
U.S. which is included on the district Section 10 list and/or is subject to the ebb and flow of
the title.
8 A Corps JD is required in order obtain my local/state authorization.
I intend to contest jurisdiction over a particular aquatic resource and request the Corps
confirm that jurisdiction does/does not exist over the aquatic resource on the parcel.
❑ i believe that the site may be comprised entirely of dry land.
❑ Other:
For NCDOT requests following the current NCDOT/USACE protocols, skip to Part E.
If there are multiple parcels owned by different parties, please provide the following for each additional parcel on a
continuation sheet.
` whist provide agent authorization form/letter signed by owner(s).
Version: Nlay 2017 Page 3

Jurisdictional Determination Request
A. PARCEL INFORMATION
Street Address: 0 McCoy Rd
City, State: Salisbury, NC
County: Rowan
Parcel Index Numbers) (PIN): #335-049
B. REQUESTOR INFORMATION
Name: David Perry - WK Dickson
Mailing Address: 616 Colonade Dr
Charlotte, NC 28205
Telephone Number: 704-227-3408
Electronic Mail Address: [e-mail]
Select one:
I am the current property owner.
I am an Authorized Agent or Environmental Consultant
Interested Buyer or Under Contract to Purchase
Other, please explain.
C. PROPERTY OWNER INFORMATION
Narne: Rowan County YMCA
Mailing Address: PO BOX 1575
Salisbury, NC 28144
® Telephone Number: G �( ( D 12
Q Electronic Mail Address: �. Q /�y� a�-� Aa w'4Yr /5' O
' Must provide completed Agent Authorization Fonn/Letter.
' Documentation orownership also needs to be provided with request (copy of Deed, County GIS/Parcel%Tax Record).
Version: Alay 2017 Page 2