NCC223377_FRO Submitted_20220928

/11
APPUCA'ITO1N FOR FERL(IT FOR A File #
LAND DISTURBING ACT IMY
Under the conditions set forth by LD Fcc Rcvicw Are
The New Hannover County
Soil Erosion and Sedimentmdon Control Ordinmxe
Bate Pd'___Datr Pd
Engineering Department
Applicant or Applicant's Agent:
Mauling Address: Telephone Number: _ Fax Number:
Entail Address:
tttrbazcz 0R pm fG t % �� •
,ice._ I�rpose o€a�evelo nt: l �'. f ��,� 1� Tow Acres of Land Dis1r 4
Description of Land Disturbance: z ov o4' trzcs aA4 A ooL4 ; 0,0 - Ast" if r-W
Address of Land Disturbance 1607 %rra�.Gri Latitude:__ I.oitgztnde:
I,wW owner(s) of rewrd:
Natrae: ,,. (�fi GpH Wo PAVA)AiDA
Address: AR159 L14 IF
City/State: W) L
Zip Cade:
Telephone Number:
Email: 145 4yAcn1
STA'i' DO NT OF IFWANCIAL RESPONSII H"Y
Peron or firm(s) 6nancfaliy rrsponss'ble for the
laad disturbing activity. If not a Now Carolina
resident, you MUST have a N.C. agent. CUA below)
Name: D h .
Address: I405r7 7A ROk LW
city/state: j t M) A,& `,,U AA
Zip Code: 2 R t-f Q "
Telephone Number: 13 79 S 78?
t?mail�l�iu`iAtiAfB�i:F/Lt 0_4�1W)L •&FaxNumber.
Location oil deeds) or instrument(s): County:%T) _�%. n o v�-!' Book: Page:.
The above information is true and correct to the best of my knowledge and belief and was provided by me wbiiie under oa&
rrhis form must be signed by ft fmancialiy responsible person if an individual and by an officer, director, partner, aszorncy-in-
fact, or Other person of authorhy to execute insumnents for the financially responsible person if not sn individual.) I agree to
provide corrected information should there be any change in the infonnation provided herein.
Z)ase: - a7 - a Nano . — _�- 6 Title ow 9�
Signature
II a Notary Public of the County of & W ill LL4 wnla,,= state of
North23hina, he�ceMfY'
J r ' appeared personally before me, this day and
being duly sworn acknowledged that the above form was executed by him`
Witness m hared and ncu�ary thin day of 2m o�
Notary lt�dy comffii$sion expires
re=jssdon to I nee on
I certify that I am eatborized to grant and do i
the land in question in connection related to th
Rrosion Control Inspector and his agents to enter on
Application Signatare and Date
PLyASE CoMpLM ALL pORTIONS a F APPLICATION
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