NCC230801_FRO Submitted_20230327

FINANCIAL 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 Henderson County Site Development Department. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Sign the original form in BLUE INK.
Part A.
1. Project Name Twin Springs Estates
2.
Location of land -disturbing activity: County Henderson
Highway/Street Twin Springs Road Latitude 35.23'47"
City Hendersonville
Longitude "82.24'50"
Property Identification Number(s) PIN's 9651886323
3. Approximate date land -disturbing activity will commence: Upon approval
4. Purpose of development (residential, commercial, industrial, institutional, etc.); Residential
13
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.52
6. Amount of fee enclosed: $ 1,400.00 . The application fee of $300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a $200.00 plan review fee to
land disturbance fees. (Example; 8.10 ac = $2,900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosedyes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Oleg Korchican E-mail Address olegP Hejvr i_1- c- , c o v­
Telephone [92,8) 230 —770 0
3. Landowner(s) of Record (attach accompanied page to list additional owners):
Longlife Properties, L.L.C. r2,S Lt 2, o — it Li
Name Telephone
1000 f1�eh� �� ps^�ut I f f oc)o �}✓ev,t'�n�yrV� , /? i 1-7
Current Mailing Address Current Street Address
Arm NC `J70(A A�-de­, NL V70�1
City State Zip City State Zip
10. Deed Book No. 3682 Page No. 77 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.
Na E-mall Addr s
Current Mailing Address Current Street Address
Asc t!_ /VL 2SJo1 A -k Al 970
City - State Zip^ City State Zip
Telephone ��S �� Z�Q l fl S H Fax Number.

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
(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:
Name of Registered Agent E-mail Address
WU AVa, Ti i*e_ Ur'i JL 1 Ato) A III woo 1P_,k, _, I1�0,)--
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Ca,sy) 2`IO _ IIS1
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 attomey-i n -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.
PC, CA(,Ck Ov-GL, 1--
Type of print name
Signature
Title or Authority
11 22
Dat
�o\fCA •.A�7, , a Notary Public of the County of Krk Cc
LtLc
State of itf 04\A Co�ca1� N � , hereby certify that fit)a 4+\G �CQ Q i /�
appeared personally before me this day and being duly sworn acknowledge that the above
form was executed by him. , r
Witness my hand and notarial seal, this A� day of N,OdJZ uk�t 20 22
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