NCC230147_FRO Submitted_20230119

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may inrtiate any land -disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit. before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Scction, 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 applicavle or the e-mail address or phone
number is unavailable, place NrA in the blank.)
Part A.
1. Project Name Hollar residence
'it (tuts project involves Arnencan Rescue Plan Act 1KHrAp Wada, r,sr Me Project r,ralnL- &e;cA+•
tinder which you applied for funding through the Division of Wafer lnfrastrvctlrre (D Wfl
2 Location of land disturbing activity' County Caldwell City ar Township Granite Fails
i_, �tiss�,y
Highwayi5treet 394 Scenic Ln Latitude„��..a:,�r•,••. Lrngitude,,n�:.m,� d�-••�
3 Approximate date land -disturbing activity wdl cornmence Janua' I 2023 _
4 Purpose of development (residential, commercial, industrial, institutional, etc.) residen I.Ial
5 Tolal acreage disturbed or uncovered (including off -site borrow and waste areas,. "'" acre
6 Amount of fee enclosed $ 100.00 The application tee of $100 00 per acre (ruunded
up to the next acre) is d5sessed without a ceiling amount {Example 8.10-acre application fee is $900)
Checks should be addressed to NCDEQ
T Has an eru5ior and sediment control plan been filed? Yes ❑ Efa fused Qx Nu ❑
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJosh Hollar E-mail Address joShhollar711@outlook com
Phone: Off;ce # I /A Mobile # [phone]
q. Landowner(s) of Record tattach accompanied page to list additional owners)'
Josh Hollar NIA 828-302-8498
Name
160 Patrick Murphy Dr. #39
Current Mailing Address
Morganton,NC 28555
Phone Office # Mobile #
160 Patrick Murphy Dr. #39
Current Street Address
Morganton,NC 28655
City Slate Zip City
10 Deed Book No 206QPage No 887
State
Zip
Provide a copy of the mast current deed

Part B.
1. Company(iss) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a soie prop6worsho or If the landowner(s) is
an indivldual(s), the name(s) of me owners) may be listed as the financially responsible partyllies).
Josh Hollar
Company Name
150 Patrick Murphy Dr. #39
Current Mailing Address
Morganton NC 28655
City
Phone: Mice # NIA
State Zip
joshhollar791 @outlook.com
E-mail Address
160 Patrick Murphy Cyr. #39
Current Street Address
Morganton NC 28655
Ciiy State zip
Mobile # [phone]
Nota: If tho pinaneislly Responsible Party is not the owner of the land to ha diisturW. inrliidp with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated lend disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
W If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
NIA
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
city State zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) if the Financially Responsible Party is engaging in business under an assumed nam, give name under
which the company is Doing Business As. If the Financially Responsible party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
NIA
Company 08A Name
The above information is true and correct to tha 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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Josh Hollar
Type or print game A f
AA,
i 7�h�
_Land owner
Title or Authority
Ola3 ao3
Date
1,( ps , �,Qp l� , a Notary Public of the County of Dt4lc
State of North Carol Ina, hereby certify that l LAA-iz— appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by himther.
Witness my hand and notarial seal, this -3" day of JOrWVp4M 20
r�w �-
(--� - pvu�
My commission expires

Continued from items 9 & fA in Part A of the Financial ResponslbilitylOwnership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record'
Bethany Hollar
N/A 828-292-9474
Name
Phone: Ofce # Mobile #
160 Patrick Murphy Dr. ##39
160 Patrick Murphy dr. #39
Current Mailing Address
Current Street Address
Morganton NC 28655
Morganton NC 28655
City State Zip
City state Zip
Deed Beck No. 2069 Page No.
887 Provide a copy of the most current deed.
Landowner 3 of Record:
NIA
Name
Phone. Office # Mobile #
Currant Mailing Address
Current Street Address
City state Zip
City state Zip
Deed Book No. Page No.
Provide a copy of the most current deed.
Landowner of Record:
N/A
_
Name
Phone: Office # Mobile #
Current Street Address
Current Mailing Address
City State Zip City
Deed Book No, Page No
Landowner 5 of Record:
NIA
Name
Current Mailing Address
State
Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
City State Zip City State Zip
[Deed Book No. Page No. Provide a copy of the most current deed.