NCC230714_FRO Submitted_20230317

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name DENC Black Mountain M-204
2. Location of land -disturbing activity: County Buncombe City or Township Swannanoa
Old US Hwy 70 N 35.603147° W 82.392611°
Highway/Street Latltude(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Installation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.0
6. Amount of fee enclosed: $ 600 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andrew Moore E-mail Address [e-mail]
Phone: Office # 704-810-3259 Mobile # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
David & Carolyn Stewart N/A N/A
Name
PO Box 636
Current Mailing Address
Black Mountain NC 28711
Phone: Office # Mobile #
2492 US 70 Hwy
Current Street Address
Swannanoa NC 28778
City State Zip City
10. Deed Book No. 6078 Page No. 1379
State
M
Provide a copy of the most current deed.

(c) If the Financially Responsible Party is engaging in business under an assumed name, 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.
N/A
Company DBA Name
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(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.
Andrew Moore Director — Engineering & Construction
Ty e or int name
Signature
Title or ut�2_2_
y
- '71 91 Date
I, - mrfo a Notary Public of the County of —C iy
State of North Carolina, hereby certify that Alli ff appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this tday of 20 ZZ
C
THIA M. ALVARADONOTARY PUBLICGaston CountyNorth Carolina �5mission Expires--
—
N ary ,�
My commission expires. Qcio r WE

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Buncombe County
Name
60 Court PLZ, Room 301
Current Mailing Address
Asheville NC 28801
City State
Deed Book No. 4374
N/A
Phone: Office #
504 Old US 70 Hwy
N/A
Mobile #
Current Street Address
Swannanoa NC 28778
Zip City State Zip
Page No. 136 Provide a copy of the most current deed.
Landowner 3 of Record:
John Kelso as Trustee of the 2012 Wright GST Trust UAD N/A N/A
Name Phone: Office # Mobile #
11 N. Market St 206 Grovemont Ave
Current Mailing Address
Asheville NC 28801
City State
Deed Book No. 6023
Landowner 4 of Record:
N/A
Current Street Address
Swannanoa NC 28778
Zip City State Zip
Page No. 25 Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current 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 5 of Record:
N/A
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.