NCC221132_FRO Submitted_20220322

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, '/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.)
Part A.
1. Project Name Wheatfield Subdivision Ph 1 - Sec 2
2. Location of land -disturbing activity: County_ Iredell City or Township Chambersburg
Highway/Street Ostwalt Amity Rd Latitude 35.700722 Longitude-80.808575
3. Approximate date land -disturbing activity will commence: lebruary 2022
4
5
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.22 aC
6. Amount of fee enclosed: $ 1,225 . 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 $1575). 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 NZ No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Matthew Silmser E-mail Address [e-mail]
Telephone
Cell # 336-362-1748 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MJ Silmser Corp _ 336-362-1748
Name YZ PS Telephone Fax Number
Current Mailing Address Z70 24 Current Street Address
NC
City State Zip City State Zip
10. Deed Book No. 2477 Page No. 1415 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):
MJ Silmser Corp _
Name
Current Mailing Address
City
NC
[e-mail]
E-mail Address
Current Street Address
State Zip City
Telephone [phone] Fax Number.
State
Zip
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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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Telephone 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 City
Telephone 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.
Matthew Silmser
Type or pr4,gUp e
Sign�at`ure
President
Title or Authority
Date
I, L[ VUAA h ` )OVVI V t a Notary Public of the County of �> I UMV
- I M 4 A State of North Carolina, hereby certify that �/ M�'t,P,_ _ 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 ,,� day of 20 ' A
AJA
ILY BOWMAN Notary
Seq4otary Public
Stokes Co., North Carolina
My Commission Expires June 6, 2026
My commission expires
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