NCC240974_FRO Submitted_20240410

OV NTY•.to�� APPLICATION FOR PERMIT FOR A File#
LAND DISTURBING ACTIVITY
Under the conditions set forth by LD Fee Review Fee
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•t - - - The New Hanover County
;,i �i a2 Soil Erosion and Sedimentation Control Ordinance
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Engineering Department
Applicant or Applicant's Agent: SAMM-Midtown,LLC
Mailing Address: 332 Military Cutoff Road Telephone Number: 910-616-0483 Fax Number:
Wilmington,NC 28405 Email Address: [e-mail]
Total Acres of Land Disturbance: 1.6 Purpose of Development: commercial
Description of Land Disturbance: site work for commercial office building and parking
Address of Land Disturbance 2725 Iron Gate Drive Latitude:34.191216 Longitude:-77.912810
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
resident,you MUST have a N.C.agent.(List Below)
Name: Cameron Properties Land Company,LLC Name: SAMM-Midtown,LLC
Address: 1201 Glen Meade Road Address: 332 Military Cutoff Road
City/State: Wilmington,NC City/State: Wilmington,NC
Zip Code: 28401 Zip Code: 28405
Telephone Number: 910-762-2676 Telephone Number: 910-616-0483
Email:[e-mail] FaxNumber Email: [e-mail] FaxNumber:
Location of deed(s)or instrument(s): County: New Hanover Book: 1756 Page: 176
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: John S. erson Title Member Manager
Signature
I, (10 f i70 N1-e-r a Notary Public of the County of Nib,...) ICIa, (T State of
North Caro ina,hereby certify that Zo h., s• A--n 5 v n appeared personally before me this day and
being duly sworn acknowledged that the abover7 form was executed by him.
Witness my hand and seal,this 0` I `d jog B112_44 �' ,20 ar •
Notary . ,, • 1c4 oy,mission expires I ��
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SEAL z V
Permission to Enter on Land CP
I certify that I am authorized to grant and do in � ih'sion to the Erosion Control Inspector and his agents to enter on
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the land in question in connection r ted to this permit application.
Application Signature and Date
PLEASE COMPLETE ALL PORTIONS OF APPLICATION