NCC220866_FRO Submitted_20220223

No person may Initiate any land -disturbing activity on one or more acres, 1/2 acre or more inside a
watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredell County Planning & Development, Erosion control Section.
(Please type or print.)
Tart A.
1. Project Name .. /
2. Location of land -disturbing activity: County ly elk-14—_ City or Township
Highway/Street:mee_1L .. 14, Latitude Longitude
3. Approximate date.land-disturbing activity will commence: ./0 uo'u�
4. Purpose of development (residential, commercial, Industrial, institutional, etc.);
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1-0
B. Amount. of fee enclosed: $ 00 . An application fee of $175.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a 9-acre application fee is $1675). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed, a flat fee of $135.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes-_ No - _ Enclosed
8. Person to contact
_ should erosion and sediment control Issues arise durings ! land-disturbing
activity:
Naas �{r a / d �`I°]."i .vet E-mail Addres4 Y !✓ 101r,, rAel
Telephone Cell Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):.
Name Telephone Fax Number
Current Mailing Address Current Street Address
city state r Zip City State Zip
10. Bead Book No. g27f? 60. Page No. Provide a copy of the most current deed,
Part B.
1. 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):
—�` _ , CJv�'1 l! I t l �A. ip / /DV a n n. d� ;_h.._►._tam V 1i , �fi rv-"-
Name E-mail Address
S� e�tr26r4rL..,_ _.,.1.K._..r...._.
Current Mailing Address
city State Zip
Telephone "7D� _-�
Current Street Address
City State Zip
Fax Number
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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:
Name
Current Mailing Address
City
Tel
State
E-mail Address
Current Street Address
city
Fax Number
State Zip
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip
Tole
Fax Number
State Zip
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 by any change in the information provided herein.
AAOLS l�ormar�
Type or print name Title or Authority
19120,L2.
Sign Datfe
I, Scvr a�, _S._7FS*,cNAer a Notary Public of the County of Tr e A_Q_�1
State of North Carolina, hereby certify that --'bOAk q's N o appeared personally before me this day
and being duly sworn acknowledged thatthe above form was executed by him.
Witness my hand and notarial seal, this Wday of nr , 20 o2�
ep •, Notary
Seal
Notary Public — My commission expires q Jc
Iredeh County =
1-10
,C `A R 44``*��`�
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