Appendix C-Affidavit of Notification

APPLICATION FOR A MINING PERMIT
AFFIDAVIT OF NOTIFICATION
I, �ffvcK 5?1 cs w1 an applicant,or an agent, or employee of an applicant,for a
new Mining Permit,or a modification of an existing Mining Permit to add land to the permitted area,from the N.C.
Department of Environment and Natural Resources,being first duly sworn,do hereby attest that the following are all
known owners of record,both public and private,of all tracts of land that are adjoining the mining permit boundary
(including, where an adjoining tract is owned or leased by the applicant or is owned by the lessor of the mine tract,
all owners of record of tracts adjoining these tracts, that are within 1,000 feet of the mining permit boundary) and
that notice of the pending application has been caused to be mailed, by certified or registered mail, return receipt
requested, to said owners of record at their addresses shown below, such notice being given on a form provided by
the Department:
(Adjoining Landowner Name) (Address)
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(Attach additional list if necessary)
I do also attest that the following individual is the chief administrative officer of the county or municipality in which
any part of the permitted area is located and that notice of the pending application has been caused to be mailed,by
certified or registered mail, return receipt requested, to said office at the following address:
(Chief Administrative Officer Name) (Address)
[i.e.: City Manager, County Manager, Mayor, etc.]
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The above attestation was made by me while under oath to provide proof satisfactory to the Department that a
reasonable effort has been made to notify all known owners of record,both public and private, of all tracts of land
that are adjoining the mining permit boundary (including, where an adjoining tract is owned or leased by the
applicant or is owned by the lessor of the mine tract, all owners of record of tracts adjoining these tracts, that are
within 1,000 feet of the mining permit boundary)and the chief administrative officer ofthe county or municipality in
which any part of the permitted area is located in compliance with N.C.G.S.74-50(b1)and 15A NCAC 5B .0004(d).
I understand that it is the responsibility of the applicant to retain the receipts of mailing showing that the above
notices were caused tobe mailed and to provide them to the Department upon request.
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Signature of Applicant or Agent Date
If person executing Affidavit is an agent or employee of an applicant, provide the following information:
Name of applicant: STt.se.J
Title of person executing Affidavit A4ANA(.u-'f--
I, G-WDA S�'l,E Nae>c�Cl a Notary Public of the County of
State of North Carolina, do hereby certify that SqltsDtl)
appeared before me this day and under oath acknowledged that the above Affidavit was made by him/her.
Witness in hand and notarial seal, this day of yU N E 20A..
Notar . lit�t�tl fi D 15
URDA SUE NVISORG
17' .ibiic. North Carolina
n,iilax County
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