HomeMy WebLinkAboutNCC230637_FRO Submitted_20230310r) ll It f Vl l I I
�u SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department E r y E D
Re bUR L 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: 704-736-850
FEB 2 7 2023
FINANCIAL RESPONSIBILITY I OWNERSHIP FPFM NA T RES
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 has been completed and approved by the Lincoln County Natural Resources Department.
(Please type or print. If the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A
Project Nam-
2. Location of land -disturbing activity: Latitude S6 4t:� 117?� Longitude — 1, 14ZZ
Parcel Identification Number (PIN) Watershed Area efa?§!-/b U 1(Oa_,
Highway/Street Address_ ?al Mick % I—%J V1_!Sta2ka &,A Qc-e
3. Approximate date land -disturbing activity will commen
r ,, e
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): r �i
6. Amount of fee enclosed: $ 406 � . The Standard Permitting application fee of $200.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 9 acres total $1,800). The Express
Permitting application fee is a dual charge. The normal fee of $200.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight
acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres tot 1 $3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Local appointed person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name \ iCAL E-mail Add ressCa/J�M� 2AW1Q Okay ejt -S �0���1 ,
Telephone) ?t9k � � 1 — q-3G`lcc Cell # Cam)1561-- ��78 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
t�txlw AA.t� rn 5uaw'e2 60AIZA-
�u L iR �'�rs Ity1CPJh P�q - 6?4 3 A,0� ly ��3 ,2.
Name Telephone Fax Number
� 1901 D CCVA6e� C"Iel L.
Current Mailing Address Current Street Address
City State Zip
City
State
Zip
10. Deed Book No. 15 Page No. most recently filed in Lincoln County Register of Deeds.
11. Future Landowners if applicable: (attach accompanied page to list additional owners):
W�
Name Telephone
Current Mailing Address
City
Current Street Address
State Zip City
State
Fax Number
Zip
*tOS�
SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
5; 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: 704-736-8504
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
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):
1DaLrn�eA A'leliorov*{rn SQL daf`Zo�..
�kz� Yl� hNO&A �►c� v - !� �n .Der
Name E-mail Address
I i 310 cojy\l
Current Mailing Address
Current Street
40w7 �F>011 file, QKx, ?:400"1410
City State I Zip City State Zip
Telephone (�W (�L
Fax Number "J'X_
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
City State
Telephone
Current Street Address
Zip City
Fax Number
State Zip
(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 blame. If the Financially Responsible Party is a Corporation,
give name and street address of the Registered Agent:
0,41
Name of Registered Agent E-mail Address
Current Mailing Address
City State
Telephone
Current Street Address
Zip City
Fax Number
State Zip
(c) In order to facilitate Permitting, it is necessary to be able to contact the Engineer or other consultant who can
assist in providing any necessary information regarding the plan and its preparation:
Engineering Firm or other consultant E-mail Address
Current Mailing Address City State Zip
Individual contact person (type or print) elephonc Fax Number
SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: 704-736-8504
FINANCIAL RESPONSIBILITY ! OWNERSHIP FORM
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
Name of Person or Firm Name of Person or Firm
21 e 1 (47 C,p:k� 1� A)C,
Current Mailing Address Current Street Address
City Stat6 Zip City
State .Zip
Individual contact person (type or print) Individual contact person (type or print)
Telephone( V+) 4 1 ty) L TelephoneCam) qp-)
Fax Number Fax Number
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 by any change in the information provided
herein and any other associated documents. I understand that all documents that are associated with this project and
project number are parts of the complete project document.
Permission to Enter on Land
I certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents to enter on the land in question in connection and/or related to this permit.
Typq_or print name
Sign ure
1)W
Title or Authority
U-C�_-Z_ --2-3
Date
a Notary Public of the County of
State of North Carolina, hereby certify that Ni c c ° L Z— 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 1211 day of
Seal f _
My commission expires