NCC215553_FRO Submitted_20211007

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
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (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.)
Part A.
.�HORSE
a
Location of land -disturbing activity: County FRANKLIN
Highway/Street ANTIQUE ®RIVE Latitude 36*06'10"N
City or Township N/A
Longitude 78*31'45"W
3. Approximate date land -disturbing activity will commence: May 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.25 Ac.
6. Amount of fee enclosed: $ 1 �040 The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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:
NameJOHN SANTORO E-mail Address
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
IRON HORSE PROPERTIES, LLC 919-771-6011
Name Telephone Fax Number
128 WIND CHIME COURT 128 WIND CHIME COURT
Current Mailing Address Current Street Address
RALEIGH, NC 27615 RALEIGH, NC 27615
city
10. Deed Book No. N/A
State Zip
City
Page No. NSA
State
0
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 orhrm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
IRON HORSE PROPERTIES, LLC (ATTN: JOHN SANTORO) [e-mail]
Name
128 WIND CHIME COURT
Current Mailing Address
RALEIGH, NC 27615
city
State Zip
Telephone [phone]
E-mail Address
128 WIND CHIME COURT
Current Street Address
RALEIGH, NC 27615
City State Zip
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:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 be any change in the information provided herein.
Type or
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Title or Authority
Date
4/Zlo /21
I, C�rt4; n Q lA 1c- R1OM Notary Public of the County of
State of North Carolina, hereby certify that JC)V) r-) S . Slarappeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
feyeenreeu e
Witness my hao�%ar ,t`tal,seal, this — day of �� 20�_
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