NCC230614_FRO Submitted_20230310

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 N/A in the blank.)
Part A. Twin Lakes Lot 16
1. Project Name
2
3.
4.
Location of land -disturbing activity: County Union
City or Township Matthews
High way/Street 111 Pecan Cove Ln�Latitude35.02082
Longitude-80.69683
Approximate date land -disturbing activity will commence: 04/01 /2022
Purpose of development (residential, commercial, industrial, institutional, etc.):_Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):. 0.41
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 James Vande Logt E-mail [e-mail]
Telephone n/a Cell # 847.809.5752 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kristen and James VandeLogt 847.809.5752 n/a
ame Telephone Fax Number
2001 Trading Path Ln 2001 Trading Path Ln
Current Mailing Address Current Street Address
Waxhaw NC 28173 Waxhaw NC 28173
City State Zip City State Zip
10, Deed Book No.8452 Page No. 231 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.
James VandeLogt [e-mail]
Name E-mail Address
2001 Trading Path Ln
Current Mailing Address
Waxhaw NC 28173
City
State Zip
Telephone_. 847.809.5752
2001 Trading Path Ln
Current Street Address
Waxhaw NC
City State
Fax Number n/a
28173
Zip

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
Current Mailing Address
City State Zip
Telephone,
E-maii Address
Current Street Address
City State Zip
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:
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
(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 Email Address
Matthew C. Kirchner
Individual contact person (type or print)
704-882-4222
Telephone
1-866-775-0329
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,
James Vande Logt
Type p 'nt n me
Signatur
Property Owner/ Developer
Title or Authority
!- Z6"'ZV23
Date
I, Aa 1-1 • \ yC -,Y-1 , a Notary Public of the County of _�, r�[ o r)
State of North Carolina, hereby certify that James VandeLogt appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this dayof 2p
]� � ands--�
Notary ` I
Haley A Hardin My commission expires I t[ 1 ao a u
NOTARY PUBLIC
Union County
North Carolina
My Comm. Expires November 7, 2026