NCC231061_FRO Submitted_20230419

Na person may iri.itiate any lane �disturbin j activity , h pne br'xnore acres as coveretl by the Act, including any
;;activityunder.;a common`plan of development of this size as'covered by he NGG01 permit; before this form
'and, an acceptable, erosion;;and sedimer tation coptro;l: plan have been completed and approyed'by the .Land
'Quality Section, N G Department'.:Qf Environmental Quality. Submit, the completed form to the. appropriate
:Regional Office (Please type or` print arid, tf the' quastfion is not applicab a .or: the e-mail' address or phone
numberis unavailable, place N/A in the blank )
1 Project' Name 4 4 0 l lei ,Rf L�l Lei I 22- U1[ �k.l E wont ` . C'Lus
'!f this project 1nvQJves American Re�c�te flan .Aci (ARPA) funds, list the Project Naine below
under which yqu ap'lied for funclfng through. the. pivision of Water Infrastructure (DWI). .
2 ;Location of land -disturbing. ar,1vity:,.Qounty CAi-byCtiaL City or Township 1�.,:��%AM$.q
Highw8y/Street 100S (31G .'VIEW LN Latltude(declma) '%g 0 LongltUde(decimal deyrees)- 81>J 740
..3. Approximate date land -disturbing activity will commence: APRI L t°7 2023
4. Purpose of.development (residential, commercial, industrial,: institutional, etc.): i2�s 1:6Et i (AL.
5. Total acreage disturbed or uncovered (includin.g off -site borrow' and waste areas): l , 54 A e
6.- Amount of fee enclosed: $ t Oelt 260 TQ aL) . The application fee of $100.00 per acre (rounded
up to the next acre) isassessed 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 R Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name JOL-(ti E-mail Address MYJ0V-(N 31 G 6VA—V. NE T
Phone: Office # M /A Mobile # 3oS �i-12`tS
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jt71 ini j lOtJl21 ` MA2rAOIVEL Nt/A ti-t2`?S
Name Phone: Office # Mobile #
2.4- 5mow eagag, Q roc t. q 2 7s,-,cuoc; ezEaK fzA nib
Current Mailing Address' Current Street Address
City State Zip City State Zip
10. Deed Book No. 20-79 Page No. FZ I L4 - t 2'16 Provide a copy of the most current deed.
,1 1

-Part B.
1. Company(ies) 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 sole proprietorship or if the landowner(s) is
an.individual(s), the name(s) of the owner(s)maybe listed as the financially responsible party(ies).
�( (<I 10Ut2 t oytrN 3 t (P A -
Company Name E-mail Address .
Current Mailing Address Current Street Address
ti.Cf�c N 2�60(
City -T"" State Zip City �! State Zip
Phone: Office # _ iV Mobile # S0_5-`7 qq-LZc.0 3
Note: If the Financially. Responsible Parry is not the owner of the land to be disturbed, include 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 land 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:
Name of Registered Agent E=mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City
State Zip City
Phone: Office # Mobile #
State Zip

(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.
141
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.
OwK-V-_a2
Typ o print name, Title or Authority ---
6th0 3
S' natur Date
- - - --- . - - -- - - - -- - - ---- - ---- --- ------ ----- - ----------------- --- --
3
Notary Public of the County of _ l 4-t'0- L/q
J
State of North Carolina, hereby certify that _ S'nhn
:.Ebr'�,L-r'i 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 day of, cuo V-t l 20 2 �
J HUNEYCUTTNotary Public
Caldwell Co., North CarolinaL.PHOE151E
Commission ix
des duly 30, 2Q24