NCC240454_FRO Submitted_20240216

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
• EXPRESS PERMITTING OPTION
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.
1. Project Name Worship Center Building
2. Location of land-disturbing activity: County Lincoln City or Township Iron station
Highway/Street NC-27 Latitude 35.4486 Longitude -81.1558
3. Approximate date land-disturbing activity will commence: 2/26/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.60
6. Amount of fee enclosed: $ . The Express Permitting application fee is a dual
charge. The normal fee of$65.00 per acre (rounded up to the next 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).
7. Has an erosion and sediment control plan been filed? Yes x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Justin Kestler E-mail Address [e-mail]
Telephone Cell# [phone] Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Hugh Whitfeild �O y -'�
Name Telephone Fax Number
4657 E NC-27 Same as mailing address
Current Mailing Address Current Street Address
Iron Station NC 28080
City State Zip City State Zip
10. Deed Book No. 607 Page No. 680 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 fthe owner or manager may be listed as the financially responsible party.
Pe,r l3up4+'-gA' 0.4 I-INIcbte. co-Afvf ht11. A,(1tlora eta( I ►"e - .or9
Name E-mail Address
51 1 *pi 9-1. Same as mailing address
Current Mailing Address Current Street Address
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City State Zip City State Zip