NCC233774_FRO Submitted_20231221

GovNTy.,�,o APPLICATION FOR PERMIT FOR A File#
A ��.s. LAND DISTURBING ACTIVITY
I r Under the conditions set forth by LD Fee Review Fee
;,.c•,`
w -{ 2 The New Hanover County
I 1 -' Soil Erosion and Sedimentation Control Ordinance
Date Pd Date Pd
•f�'4Dntsli6D 11-
Engineering Department
Applicant or Applicant's Agent: Sheetz, Inc.
Mailing Address:5700 SIXTH AVE,ALTOONA, PA 16602 Telephone Number: 919-2648593 Fax Number:
Email Address: [e-mail]
Total Acres of Land Disturbance: 3.31 Purpose of Development:sheetz general retail,fuel pumps,restaurant,drive-through,vehicle wa
Description of Land Disturbance: Land disturbance to construct Sheetz general retail,fuel pumps,restaurant,drive-through,vehicle wash
Address of Land Disturbance 2435 Independence Blvd,Wilmington,NC 28403 Latitude: 34.196035 Longitude:-77.908419
STATEMENT OF FINANCIAL RESPONSIBILITY
Land owner(s) of record: Person or firm(s)financially responsible for the
land disturbing activity. If not a North Carolina
resident,you MUST have a N.C.agent. (List Below)
Name: Graham-Cameron Land, LLC Name: Sheetz,Inc.(Brian Downs)
Address: 2512 Independence Blvd Ste 200 Address: 2626 Glenwood Avenue, Suite 550
City/State: Wilmington, NC City/State: Raleigh, NC
Zip Code: 28403 Zip Code: 27608
Telephone Number: 910-769-4548 Telephone Number: 919-2648593
Email: [e-mail] FaxNumber Email: bdowns@_sheetz.com FaxNumber:
Location of deed(s)or instrument(s): County: New Hanover County Book: 6079 Page: 358
The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath.
(This form must be signed by the financially responsible person if an individual and by an officer, director, partner, attorney-in-
fact, or other person of authority to execute instruments for the financially responsible person if not an individual.) I agree to
provide corrected information should there be any change in the information provided herein.
Date: /41 /2 Na toAugustine Title VP of Store Development
Signature -
g �l
I, f t,//1c/ r-/-d ey a Notary Public of the County of 6/4 1‘.-- State of
,hereby certify that Sieved-7 I? 47,743f1•-,<__ appeared personally before me this day and
being duly sworn acknowledged that the above form was executed by him.
Witness my h/a d and notary seal,this 1/fr1 day of bee ern he.,,-- ,20. 23 .
Notary ' )UGC /r,,7P. -u_y My commission expires //- 9-Z-7
Commonwealth of Pennsylvania-Notary Seal
SEAL Kayley Ritchey,Notary Public
Blair County
My commission expires November 9,2027
Commission number 1436119
Permission to Enter on Land Member,Pennsylvania Association of Notaries
I certify that I am authorized to grant and do in fact grant permission to the Erosion Control Inspector and his agents to enter on
the land in question in Conn 'on rel ted to ' permi application.
Application Sign ure and Date
PLEASE COMPLETE ALL PORTIONS OF APPLICATION