NCC223837_FRO Submitted_20221207

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 N/A in the blank.)
Part A. Briar Creek and Paw Creek Sewer Rehabilitation
1. Project Name
R
3
4
Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Sharon Rd/Chilton PI; Wilkinson 35.180-80.829
Highway/Street Blvd, Old Dowd Rd Latitude Longitude
Approximate date land -disturbing activity will commence: October 1, 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Public Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.1
6. Amount of fee enclosed: $ 325 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Richelle Hines E-mail Address [e-mail]
Telephone [phone] Cell # N/A Fax # N/A
91
Landowner(s) of Record (attach accompanied page to list additional owners):
City of Charlotte (utility right-of-way) 704-336-7600
Name Telephone
600 E 4th St 600 E 4th St
Current Mailing Address Current Street Address
Charlotte, NC 28202 Charlotte, NC 28202
City
10, Deed Book
State Zip City
N/A Page No, N/A
*on utility right-of-way
State
N/A
Fax Number
Zip
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.
Charlotte Water (Carl Wilson, P.E.) [e-mail]
Name E-mail Address
5100 Brookshire Boulevard 5100 Brookshire Boulevard
Current Mailing Address Current Street Address
Charlotte, NC 28216 Charlotte, NC 28216
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
N/A
N/A
Name
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State Zip
City State Zip
Telephone N/A
Fax Number N/A
(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:
N/A
N/A
Name of Registered Agent
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
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.
Joseph C. Wilson, P.E. Chief Engineer
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Title or Authority
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Date
I, Er�>� j.�� Y'G�/ a Notary Public of the County of elan e_n bLQ
State of North Carolina, hereby certify that h C Wl L Ski appeared
personally before me this day and being duly s orn acknowledged that the above form was
executed by him.
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Witne�AyLtea d® tarial seal, this `'l day of 20�
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