SW3140101_COMPLIANCE_20140421

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
DOC TYPE ❑ CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
COMPLIANCE EVALUATION INSPECTION
DOC DATE �IOIO�a�
YYYYMMDD

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
form and an acceptable erosion and sedimentation control plan have been completed and apprc
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type_ or,
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in th('blai
Part A.
1. Project
before this
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2. Location of land -disturbing activity: County Union City or Township Marshville Ap
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Highway/Street Hasty Road Latitude 34,97783 Longitude-80.341641 � Z m
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3. Approximate date land -disturbing activity will commence: July 15, 20'i4
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):18 Prev. 19.04 Total
6. Amount of fee enclosed: 130 . 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
Telephone
Cell #
E-mail
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Current Mailing Address
City State Zip
10. Deed Book
Part B.
Page
Telephone Fax Number
Current Street Address
City State Zip
Provide a copy of the most current deed.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Name
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
City
2M
Telephone Fax

(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 State Zip
Address
Current Street Address
City State Zip
Fax Num
(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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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 anv chanoe in the information provided herein.

Wade, Larry
From: Wade, Larry
Sent: Monday, March 31, 2014 3:18 PM
To: 'Cindy Flehan'
Subject: SW3140101 Permit Revision Hasty Rd. Development
Ms. Flehan,
After reviewing the subject submittal received on March 27, 2014, 1 have found the submittal lacking the following
items:
1. Please provide a short narrative or description what the specific revision consist of.
2. Provide an executed application with the revised information. There is a box to check on the application for
a modification to an existing permit. Also provide a copy of the original application that was approved if you
have that available.
3. The checklist provided in the Low Density Supplement was not initialed. Please complete this sheet and
include with your submittal.
4. A Financial Responsibility Ownership Form used to secure a grading permit was included in your submittal.
Grading permits are obtained through our regional offices. If you need this form returned to you, please let
me know.
5. Any additional information relative to the revision, (calculations or supporting documentation) if necessary.
Please provide two copies of all information. One copy will be returned to the owner, and one copy will be forwarded to
our regional office staff. If you have any questions please let me know.
Larry W. Wade PE Telephone: [phone]
Fax: [phone]
Stormwater Permitting Program
North Carolina Department of Environment & Natural Resources
Division of Energy Mineral and Land Resources
1612 Mail Service Physical Address - 512 N. Salisbury St. Room
9425
Raleigh, NC 27699-1612 Raleigh, NC 27604
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