NCC240560_FRO Submitted_20240228

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM _ Ce
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 N/A in the blank.)
Sign the original form in BLUE INK
Part A.
1 . Project NameOrchards Edge Retreat
2. Location of land-disturbing activity: County Henderson City Hendersonville
Highway/Street 1600 Jeter Mountain RD Latitude 35.2535401 N Longitude 82.5639958W
Property Identification Number(s) PIN's 9563-57-5870
3. Approximate date land-disturbing activity will commence 3/01 /2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.)_ Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.49
6. Amount of fee enclosed $ $2000 . 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity.
Name Jonathan Brussee E-mail Address [e-mail]
Telephone [phone]
9 Landowner(s) of Record (attach accompanied page to list additional owners):
Orchard's Edge Retreat, LLC 828-808-8059
Name Telephone
874 Jeter Mountain RD 874 Jeter Mountain RD
Current Mailing Address Current Street Address
Hendersonville NC 28739 Hendersonville NC 28T39
City State Zip City State Zip
10. Deed Book No. 4027 Page No. 511 -513 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 ttio company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Orchard's Edge Retreat, LLC [e-mail]
E-mail Address
874 Jeter Mountain RD 874 Jeter Mountain RD
Current Mailing Address Current Street Address
Hendersonville NCr,ii Hendersonville NC 28739
City State Zip City State Zip
Telephone [phone] Fax Number