NCC223855_FRO Submitted_20221118

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:
Nla
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Nla
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express 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:
Eagle Engineering, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Steven Prophet 7048824222 7043155735
Individual contact person (type or print) Telephone 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 be
any change in the information provided herein.
Edgar and Danitra Barnett Owner
Corr print nrme itle or AutYklAtw
Signature ' Date
---------------------------- --------------------------------------------------------------------------------------------------------- -
I, 912.i a Notary Public of the County of ,y:� tee"
State ofPAenlMarolina, hereby certify that �a- � 'DaV) l� VYYI t { appeared personally
before me this day and being duly sworn acknowlbdged that the above form was executed by him.
Witness my hand and notarial seal, this 19 day of
`tpnnririp,r,° r
���,•'�� MICH,��r,,,r
wciB<���, Notary
My commission expires REMA
� _ I � �.^. •. ':Sly M

FINANCIAL. RESPONSIBIL.ITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 have been completed and approved
by the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/or
fax information unavailable, place NIA in the blank.)
Part A. Twin Lakes Lot 7
1. Project Name
Location of land -disturbing activity: County Union City or Township Matthews
Highway/Street River Birch Ln Latitude 35.0192 Longitude-80.7000
3. Approximate date land -disturbing activity will commence: 4/4/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): '80
6. Amount of fee enclosed: $ 350 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per 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 is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Edgar and Danitra Barnett E-mail Add
Telephone [phone]
Cell #
Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Edgar and Danitra Barnett 858-401-9000 nla
Name Telephone Fax Number
109 Jones Creek Circle 109 Jones Creek Circle
Current Mailing Address Current Street Address
Anderson, SC 29621 Anderson, SC 29621
City State Zip City State Zip
10. Deed Book No. 8416 Page No. 012 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Edgar and Danitra Barnett
Name E-mail Address
109 Jones Creek Circle 109 Jones Creek Circle
Current Mailing Address Current Street Address
Anderson, SC 29621 Anderson, SC 29621
City State Zip City State Zip
Telephone [phone] Fax Number n/a