NCC222875_FRO Submitted_20220812

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
Resoi,R cs 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]�1
FINANCIAL RESPONSIBILITY/ 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 _ I
t. Project Name - �r'Gil Er[�1Cty5tb M Humes
2. Location of land -disturbing activity: Latitude 3s. %a Longitude 7 y14
Parcel Identification Number (PIN) 1092kA -t 10ZV4 b Watershed Area
I
Highway/Street Address a 71 + 133 "ood up wo_u NC IRC C)
3. Approximate date land -disturbing activity will commence: &A P
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Res ► C� erg t �� --
5. Total acreage disturbed or uncovered (including oft -site borrow and waste areas): I . 5 GICreS
vU
6. Amount of fee enclosed: $ Uo . 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 appointed person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name 3 cn 1-tc�.�. N. l � E-mail Address Be.� (a)r��•�SC n d Coll Si rvcc %V 4 r.o
Telephone 704 - - b 13 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
�>rrztls �r,ci � Est�,-lT �-- 6 l 9.419 9 W i U � ctm H aftiffi 1
Name Telephone Fir Corftf-+
I j `14S 4r� le, PrjA Lane -
Current Mailing Address Current Street Address
lAun+m6lLeZ
Ci State Zip City State Zip
10. Deed Book No3Cq2 Page No. most recently filed in Lincoln County Register of Deeds.
3 oq 2 5533
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

y�°y� c ° SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
Re�Psbu`cs 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 responsible parties on an attached sheet):
�r � jS end � US �(. rv►eS. Ll e-ben @ . Co
Name pp ww E-mail Address
1) IOU 'hwWotid Larit
Current Mailirr Address Current Street Address
VrI+e(_SV)L 2M8
City State Zip City
Telephone -70q %0-2 13 Fax Number
State Zip
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 State Zip
Telephone
E-mail Address
Current Street Address
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 State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
(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 Address
Current Mailing Address City State Zip
Individual contact person (type or print) Telephone Fax Number

° N co a SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
snTURAL 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
Rt50CIRG[5
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
�l��nc1 Ct�s+cn� bamcs. Lr�
Name of Person or Firm Name of Person or Firm
Current Mailirq Address
1- DVAersvill'e Nt Z9016
ty I State Zip
Current Street Address
City
State Zip
&a Gmrn►1 l - -
Individual contact person (type or print) Individual contact person (type or print)
Telephone _7t%�" q!eQ - 2(013 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.
_l en - �a.n•.,,
Type or print name
Signat
own[/
Title or Authority
Date
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 2 ZCi
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GOB �!I
N 0 Tq9 •,. My commission expires
2�'•, C/e � f C r . .