HomeMy WebLinkAboutNCC216666_FRO Submitted_20211206FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Park Meadow Phase 11
1. Project Name
2. Location of land -disturbing activity: County Union City or Township Indian Trail
Highway/street Old Monroe Rd Latitude 35.074488 Longitude-80.684647
3. Approximate date land -disturbing activity will commence: December 15, 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): (+/-)1.96 acres
6. Amount of fee enclosed: $ 130.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lauren Thomas P.E. E-mail Address lauren.thomas@eagleonline.net
Telephone 704-893-1262 cell # 704-460-7513 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Park Meadows Development LLC
n/a n/a
Name
Telephone Fax Number
231 Post Office Dr, Suite B8
231 Post Office Dr, Suite 138
Current Mailing Address
Current Street Address
Indian Trail NC 28079
Indian Trail NC 28079
City State Zip
City State Zip
10. Deed Book No. 7193 Page No. 718 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Park Meadows Development, LLC
tcrouch@themosergroupinc.com
Name
E-mail Address
231 Post Office Dr, Suite B8
231 Post Office Dr, Suite 138
Current Mailing Address
Current Street Address
Indian Trail NC 28079
Indian Trail NC 28079
City State Zip
City State Zip
Telephone 980-333-9019
Fax Number n/a
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Wesley S. Hinson
Name of Registered Agent
309 Post Office Dr
n/a
E-mail Address
309 Post Office Dr
Current Mailing Address Current Street Address
Indian Trail NC 28079 Indian Trail NC 28079
City State Zip City State Zip
Telephone n/a Fax Number n/a
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
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Date
I, CGP��& R, L/ 16, a Notary Public of the County of
State of North Carolina, hereby certify that ( kj. S a peared
personally before me this day and being Muly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of u Pi 20
TRAENAELITTLEBLICnty Notarylina
My Cs April 16, 2022
My commission expires