20191250 Ver 1_02_Agent Authorization Form_Signed_20190919

AGENT AUTHORIZATION FORM
Name:
Address: (o S� U �� ,.� u i 06 a
Phone: 2 (01 - 5/ V U
Project Name/Description: Elliot Road Extension
Date: / O Ax V by
The Department of the Army
U.S. Army Corps of Engineers, Wilmington District
Attention: Ms. Sam Dailey
Field Office: Raleigh Resulatory Field Office
Re: Wetland Related Consulting and Permitting
To Whom It May Concern:
7 sI 1,,
The Town of Chapel Hill hereby designates and authorizes Kimley-Horn and Associates, Inc. to act in
my/our behalf as my/our agent solely for the purpose of processing Jurisdictional Determinations,
Section 404 permits/Section 401 Water Quality Certifications applications, and Jordan Lake Water
Supply Watershed Riparian Buffer Determinations, and to furnish upon request supplemental
information in support of applications, etc. from this day forward until successful completion of the
permitting process or revocation by the owner.
In addition, I, the undersigned, a duly authorized owner via linear transportation easement of the area
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.
Authorized this the day of 04 o? 0Z F
Print Responsible Party's Name
Cc: Karen Higgins
NC Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
49't'L-
Re
spdns1W Party's Signature