NCC232931_FRO Submitted_20231017

�c�"�';y'ti APPLICATION FOR PERMIT FOR A
0
�'% LAND DISTURBING ACTIVITY
File#
A \ 9 Under the conditions set forth by/ - 4' o LD Fee Review Fee
W ." z' The New Hanover County
- 04: Soil Erosion and Sedimentation Control Ordinance
�?�n is++�o`�, Date Pd Date Pd
Engineering Department
Applicant or Applicant's Agent: Andy Priolo
Mailing Address: 1100 Situs Court, Suite 100 Telephone Number: 919-774.6700 ext 5714Fax Number:
Raleigh, NC 27606 Email Address: [e-mail]
Total Acres of Land Disturbance: 5.3 Purpose of Development: Gas Station/Service Station
Description of Land Disturbance: Demo existing Circle K store,grade site,and install infrastructure as required to construct a new Circle K gas station/service station
Address of Land Disturbance 5717 and 5801 Castle Hayne Road.3928 Lynn Avenue Latitude: 34d21'29.55"N Longitude: 77d53'38.94"W
Castle Hayne,NC 28429
STATEMENT OF FINANCIAL RESPONSIBILITY
Land owner(s)of record: Person or firm(s)financially responsible for the
land disturbing activity. If not a North Carolina
South Belt Properties LLC/Green resident,you MUST have a N.C.agent. (List Below)
Name: Meadows Properties LLC(Rachel Heneghan/Alex Hall) Name: Meredith W. Rice, Jr. -Circle K Stores, Inc.
Address: P.O. Box 52085 Address: 1100 Situs Court, Suite 100
City/State: Phoenix,AZ
y City/State: Raleigh, North Carolina
Zip Code: 85072 Zip Code: 27606
Southbelt Properties Green Meadows Properties
Telephone Number: 704-529-6440 910-231-1936 Telephone Number: 919-774-6700
[e-mail]
Email: [e-mail] FaxNumber Email: [e-mail] FaxNumber:
Location of deed(s) or instrument(s): County: New Hanover County Book: 5279 Page: 1006
The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath.
(This form must be signed by the financially responsible person if an individual and by an officer, director, partner, attorney-in-
fact, or other person of authority to execute instruments for the financially responsible person if not an individual.) I agree to
provide corrected information should there be any change in the information provided herein.
Date: 11/ 7 au y\.. Name Meredith W. Rice,Jr.
Title Vice President
Signature � �27��L:V
I. P*br c) F. 11^1
a Notary Puh is of the County of `IO AS State of
North Carolina, hereby certify that 1flev o/,7f'7 it.). it/4e-7r, appeared personally before me this dayand
i
being duly sworn acknowledged that the above form was executed by him.
Witness my hand awl not•ry I, this day of �d V .20 0 7
Notary Gu c .< My commission expires a 3I Da 3
/
SEAL ROBIN F. ALFORD
Notary Public, North Carolina
' Johnston County
My Commission Expires
Permission to Enter on Land April23,2023
I certify that I am authorized to grant and do in fact grant permission to the Erosion Control Inspector and his agents to enter on
the land in question in connection related to this permit application.
"I r- hCtGrl'!�%L1
Ap
plication Signature and Date
PLEASE COMPLETE ALL PORTIONS OF APPLICATION