NCC220984_FRO Submitted_20220308

Part A.
FINANCIAL RESPONSIBILITY/OWIVER5Fp6WVED
EROSION & SEDIMENTATION CONTR(PLB p q 2022
No person may Initiate any land -disturbing activity on one or more acres, 'h acre or more inside a
watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredeli County Planning & Development, Erosion Control Section.
(Please type or print.)
1. Project Name Q U t
�f► �y Ln
2. Location of land4sturbing activity: County Q i f City or Township rlu Y I Ile
i LQ-- - 16
r INAS
Highway/Street Latitude Longitude
3. Approximate date land -disturbing activity will commence: — D
4. Purpose of development (residential, commercial, industrial, institutional, etc_).. ri—If
n�4Y ; j
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): _ r '7 aG!`e,
6. Amount of fee enclosed: $_L3,, L An application fee of $175.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a 9-acre application fee is $1575). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed, a fiat fee of $135.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes)_ No Enclosed
8. Person to contact should erosion and sediment control Issues arise during land -disturbing activity:
Name R J'Q E-mailAddress
Telephone 3 J S .Qi — ,r) ( H Cell #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Fax #
IV2-1 i saber -ram ears,
Name f R &-Lp f J"n+.e fast C" Telephone
Fax Number
Current Mailing Address -' Current Street Address
J N� �D31
City State Zip City State Zip
J�
10. Deed Book No. Page No. i 3 c�L I — ( 3 Provide a copy of the most current deed_
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all
responsible parties on an attached sheet):
Name E-mail Address �— C
Current Mailing Addre Current Street Address
m onreow ilr 'p_C CW I r S
City ate Zip City State ZIp
Telephone 3 Q S J0 1— fa 7 /4 Fax Number
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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
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 Re'sponsible Party is a Corporation, give name and street
address of the Registered\ent:
Name of Registered Agent E-m J ddress
Current Mailing Address ` Current Street Address
City
State Zip City
Telephone Fax Number
State Zip
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 atiomey-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
provid�ycorrected information should there by any change in the information provided herein.
J I�T1 Sao 4-uz' r.'JAI-e -
Type or print nalne Title or Authority
L\E I -�� �a
Signature( Date
I, i r4a •i ` r ( a Notary Public of the County of (t, 61-"C �^
State of North Carolina, hereby certify that �^ r •'C Gr r { appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 7 day of Gnu yrr , 20 ')..�-
Notary
Eat N�1lll1i11r/!,� J
`.�F�1rY MrGy' My commission expires 1
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r
My Comm Exp 10122.2024 _
Notary 1r 201930100081
N.
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