NCC221946_FRO Submitted_20220524

I. rl ll ll FUI 11I
SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
RCS�URCC 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form and an acceptable
erosion and sedimentation control plan has been completed and approved by the Lincoln County Natural Resources Department.
(Please type or print. If the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A
1. Project Name
2. Location of land -disturbing activity: Latitude '35A9 _ 34 [ Longitude — e A s 003 z'! 1/
Parcel Identification Number (PIN) 1W 07Watershed Area,�_
Highway/Street Address 3 1 ►,.lr 1, rim ♦ jt t'�Pa,� , ,,a4S—t
l
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.):�s���on
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ 400100 . The Standard Permitting application fee of $200.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 9 acres total $1,800). The Express
Permitting application fee is a dual charge. The normal fee of $200.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight
acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total $3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Local appointedperson to contact should erosion and sediment control issu[es� arise during land -disturbing activity:
1
Name � upey\ ' Q-' E-mail Address VIVanrnpC,
Telephone„%� Cell # C?a 4� &6 J -- 8Z71 Fax #
9. Landowner(s) of Record (att ch acc mpa ed page to list additional owners):
t-AC % c1 etA_ 17 3 �t-o L1 b
Name "ArL�C Telephone Fax Number
F. 6, fox le3951
Current Mailing Address Current Street Address
City /' / State Zip City State Zip
10, Deed Book No. 6(P 3 Page No. � most recently filed in Lincoln County Register of Deeds.
11, Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
Name
Current Mailing Address
City
State Zip
Telephone Fax Number
Current Street Address
City state R F C E 11� E fl
MAY 13 202?
L.C. NAl RES

(',,
SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
G�SQURC[S 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
Part B
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive
list of all responsib a parties o an att ed Peet):
�1c�- -�'-�ricch�o
�Q�s l e"Djy-, tom, .cc"q\ h9rna tau lcpl l '-sou 4kA , he
Name V]-%`Q;V W `Aj t (P E-mattAddress
P" D, '�60_\e_ -;3 2 3 a I t-A . �_1 10 1:E) use rN05.S
Current Mailing Address Current Street Address
City State II Zip City State l Zip
Telephone7r�, �� b �� ( Fax Number
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
City State
Telephon
Current Street Address
Zip 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 egistered Agent E-mail Address
Current Mailing Address
City State
Telep
Current Street Address
Zip City
Fax Number
State Zip
(c) In order to facilitate Permitting, it is necessary to be able to contact the Engineer or other consultant who can
assist in providing any necessary information regarding the plan and its preparation:
Engineering Firm or other consultant E-mail Addres
Current Mailing Address City Statd Zip
Individual contact person (type or print) Telephone Fax Number

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
#NAJC�M-Al'
5' 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
Name of Person or Firm Name of Person or Firm
Current Mailing Address
City State
Current Street Address
Zip City
State Zip
Individual contact person (type or print) Individual contact person (type or print)
Telephone Telephone
Fax Number
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 by any change in the information provided
herein and any other associated documents. I understand that all documents that are associated with this project and
project number are parts of the complete project document.
Permission to Enter on Land
I certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents to enter on the land in question in connection and/or related to this permit.
Type or prilhename �Title or Authority
6�1
Si ature Date
I, --,rA) nI � [ f t TVJJ61 l { , a Notary Public of the County of L t'4 i'� .
State of North Carolina, hereby certify that (jra�. L appeared personally before
me this day and being duly sworn acknowledged E t the above form was a ecuted by him.
Witness my hand and notarial seat, this Jday of 20Z
I, RUo�. � Notar
• ' My commission expires �J 2d2;
�ARy
Pula
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