NCC221111_FRO Submitted_20220321

Noperson may initiate any land -disturbing activity nnone mmore 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 ofEnvironment and Natural Resources. (Please type orprint and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
2. Location ofland-disturbing activity: County ­Cumberland City orTownahip__For Bragg_
H Tay Rdand Sapper 8t______
Latitude Longitude N`78"58l55^
3. Approximate date land -disturbing activity will commence: December 3U.2021_____
4. Purposeufdevoopment(neoidenba|.uummeroia[induntria|.instdutiono|.etn]:______Mi|ibamYUti|dx
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.39
G. Amount of fee enclosed: OO.. The application fee of$10U.O0 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee
7. Has enerosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Isaiah Koonce [e-mail]_____
Telephone _81O-4g5-1311Cell #01O-380-2457Fux#Q10-4Q5-131O___
0. Landowner(s) of Record (attach accompanied page to list additional owners):
Department nfDafanoe_____
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City
10. Deed Book No. P000No.
Part B.
Provide acopy ofthe most current deed.
1. or firm(s) who are financially responsible for the land -disturbing activity o
comprehensive list nfall responsible parties onanattached shaaU:
_Old North Utility Services, Inc. —Jeremy.George@asuain�com.
Name E-mail Address
__P.O. Box 73316 _2941 Lmoistics Street Building
Current Mailing Address Current Street Address
_FmrtBrmS 0387 Fort Bragg 8310
City State Zip City State Zip

Telephone [phone]
Fax Number 910-495-1210
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
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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 any change in the information provided herein.
-emy George Capital Project Supervisor I
)e or print n me Title or Authority
'22_ - W ;7
nature Date
I, �YiCI._ QGtM03 , a Notary Public of the County of C1YWO-efl"
State of North Carolina, hereby certify that Sta&AN b-f(jM-'r_ appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this E2— day of 20 2Z
C_