NCC230238_FRO Submitted_20230127

PLAN REVIEW/FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
CATAWBA COUNTY CODE OF ORDINANCES, CHAPTER 16 ARTICLE V
SOIL EROSION AND SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres as covered by the Ordinance before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Catawba County
Utilities and Engineering Department. (Please type or print, and if question is not applicable, please N/A in the blank)
PART A
1. Job Name [Riddle Residence
2. PIN or 911 Address 4357 Little Mountain road, Catawba, NC
3. Purpose of development (residential, commercial, industrial, institutional, etc.) Residential
4. Approximate soil disturbance date 12/15/22
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 2.4 AC.
6. Has an erosion and sedimentation control been filed? r yes [ No UZ Attached
7. If you have an Erosion Control billing account, would you like this to be billed? r Yes X, No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Dylan Riddle E-mail address [e-mail]
Telephone [phone]
p � Cell # 704-651-1607 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name Dylan L& Anna K. Riddle Telephone [phone] Fax # N/A
Current Mailing Address 2033 Bost Street
City Lincolnton _ [28092
---- - ----------------------------- state NC Zip
Current Street Address 2033 Bost Street
City Lincolnton State FC ;Zip 28092
10. Deed Book No. 3637 Page No. 1 s9s
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 attached sheet):
Name Dylan L. & Anna K. Riddle E-mail address [e-mail]
Current Mailing Address 2033 Bost Street
City Lincolnton State NC Zip 28092
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Current Street Address 2033 Bost Street
City Lincointon State NC _ — Zip 2H92
Telephone [phone] Fax # 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:
Name N/A E-mail address
Current Mailing Address
City State
Zip
Current Street Address
City State zip
Telephone _ Fax #
2. (b) If the financially responsible party is a Partnership or other person engaging in business under 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 N/A E-mail address
Current Mailing Address
City State �— Zip -
Current Street Address
City State Zip
Telephone Fax #
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.
ALA
Type or Ppijit Name Title of Ajuthority
Sign re Date
-e,7 , a Notary Public of the County of 7 ,, ezo / )J State of North
Carolina, hereby certify that [il--nv c2 4��1e appeared personally before me this day and being duly
sworn acknot�rle`�ge?th�at the above form was executed by him.
.r.L4r
WitnesS'my handaiidotaiy seal, this day of , kA d , 20 'Z�
otary _
My Commission expires
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