NCC230035_FRO Submitted_20230109

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may ►n+tlate any land- disturbing actrvrty our W or more acres as cxwvered by the Ad before this form
and an acceptable erosion and sedunentanon control Plan have tyeen ocmpleted and approved by the Land
Quality Section N.C. Department of Environmental Clualtty Submit the completed forth to tits aRProPnate
Reg*nal Off" {Ploaw type or pant and, if the question is not applrcaWe or the e-mail address or phone
number is unavarlaole. place NIA in the blank )
Part A.
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Pfojw Name 252 Eaton Road, Mocksville, NC
Location of #and -disturbing Wmty County Davie City or Townsnrp Mocksville
H►ghwa3ytStreet Eaton Road I SR 1600 l...abtude(-www oPvw". 35.879 Lof9tvde:a,,,.,r aver . ; -80.553
Approximate date dar4-distwbrrig acftvrty will commerce under NOV
Pur-pose of deveioPmerit (residential, commarcial. rndu5tnar institutional etc t Commercial
Total acreage desturt>ed or uncovered (including Off -'Site harrow and wash areas) 4.8
Amount of fee enciosed $500 The appircatrnn fee of $100.00 per acre (rounded
Lip to the next acre) is assesse-0 without a ceiling arnouni (Example 8 1 L -acre appixatron fee is S900)
Checks should be addressed to NCDEQ
Has an eras&on and sedfinent cantros. plan (seen Filed? Yes Cl Enckmed ® No ❑
Petwn to contact should erosion and sediment control rssues arise during land -disturbing activity
Narne grad Lag le E-mail Address l agle L yadtel . net
Phone office +I Mobile # [phone]
9 Landownef(si at Record (attach accompanied page to list additional ownems
Lagle Properties. LLC 336-399-3821
Name
207 Dulin Road
Current Mailing Address
MoCkSvilie, NC 27028-7201
city
Zip
10 Dead Soak No 1206 Page No 71
Phone Office to Mobile
Same
Current Street Addres�
Same
City State Zip
Provide a copy of the mom current creed