HomeMy WebLinkAboutNCC221484_FRO Submitted_20220418DocuSign Envelope ID: 63269333-D53B-4818-9026-283F886F92F0
�"'` •�,°r APPLICATION FOR PERMIT FOR A File #
LAND DISTURBING ACTIVITY
Cd
� Uner the conditions set forth by LD Fee Review Fee
gyp, The New Hanover County
g Soil Erosion and Sedimentation Control Ordinance
Date Pd Date Pd
Engineering Department
Applicant or Applicant's Agent:
Mailing Address: JQLCQ1tCSnter Df F SAi& 1 Q)_ Telephone Number. 984-302-1451 Fax Number:
Raleigh, NC 27607 Email Address: Scott.BradslterQFredsnii[hconipaiy.net
Total Acres of Land Disturbance: 8,0 Purpose of Development: Cgmmercial Asphalt PIAUI_
Description of Land Disturbance: _SitcJ)=lapmcnl for Plant
Address of Land Disturbance ,-5600 Holly Shelter Rd. Latitude: Longitude: 77051129,73 "W
STATEMENT OF FINANCIAL RESPONSIBILITY
Land owner(s) of record: Person or firm(s) financially responsible for the
land disturbing activity. If not a North Carolina
resident, you MUST have a N.C. agent. (List Below)
Name: FSCFSC II_ t_T.C. Name: Brent Wood
Address: 701 Cnrnorate Center Dr., Suite 101 Address: 701 Corpnr a Center Dr.- Suit?,J01 _
City/State: Wej&, NC City/State: -Raleigh- NC _
Zip Code: _27607 Zip Code; 27607
Telephone Number: 919-783-5700 --Telephone Number: _919-$46-4695
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Email: 'Co" f�axNumber NiA Email: nrctt IV x rl kr}liedsn ns4ornpany.itct FaxNUmbeC: _ Nl�,
Location of deed(s) or instrument(s): County: _New Hanover Coup y Book: 6544 Page: 2941_2946
The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath.
(This form must be signed by the financially responsible person if an individual and by an officer, director, partner, attorney -in -
fact, or other person of authority to execute instruments for the finan 'ally responsible person if not an individual.) I agree to
provide corrected information should theret1 ehatlge in the inforl tion provided herein,
Date: iWnte Title JIP
Signature
I, a Notary Ptth is of the County of �'►�',t State of
North Carolina, hereby certify that kL_) _ appeared personally before me this day and
being duly sworn acknowledged that the above form was executed by him.
Witness my lend and notar sea"Z��
AAaLCA _�.20 �2
Notary l �„� M commission ex fires _
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SEAL DUSTY DRAKE BATTEN
NOTARY PUBLIC
Wake County
North Carolina
Permission to E'nte€' on Land
I certify that I am authorized to grant and do in fact grant permission to the Erosion Control Inspector and his agents to enter on
the land in question in connection related to this permit application.
Darus3gard by:
lADtS 4/5/2022
Applicattui°rSigiii€u`re and Date
PLEASE COMPLETE ALL PORTIONS OF APPLICATION