NCC241137_FRO Submitted_20240412

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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 and/
or fax information unavailable, place N/A in the blank )
Part A. 60 Sunwood Lane
1 Project Name
2 Location of land-disturbing activity: CountyChatham City or TownshipMOflCUfe
Highway/Street Sunwood Lane Latitude35.6352 Longitude-79.0901
3. Approximate date land-disturbing activity will commence.4/15/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.).Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 1 '77
6. Amount of fee enclosed: $ 200.00 . The application fee of $100 00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example. 8.10 ac = S900 00).
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 Arnold R. Inman Jr. E-mail [e-mail]
Telephone[phone] Cell# 770-402-7815 Fax# N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners)_
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Name Telephone Fax Number
<.5 C7 ran of OW/i'4/ -R.7im L53 / (fit-Arlo( (lei- ca/ S1a/i1 rl
Current Mailing Address Current Street Address
cx A/C 17so2 14 NC 1�s�-2-
Citc State Zip City State Zip
10. Deed Book No. .2 0Dy Page No. 7 oZ 1 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 the owner or manager may be listed as the financially responsible party.
Arnold R. Inman Jr. Tray, i nrnan 1'7 ,5,Q, /w comer
Name E it Address
sy`/ Cvart' Ce rIra/ Sa-di n syy C-iinfo! CertfrA 5-4-4-/,
Current Mailing Address Current Street Address
s 7So2 Pcx C 2 7,.4(.s-
Cit State Zip City State Zip
Telephone (17 2 ) qtZ -7,6/f Fax Number
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2 (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address y
of the designated North Carolina Agent
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent ,.
ti
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address ,
City State Zip City State Zip
Telephone Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Arnold R. Inman Jr. Owner
Type or print name Title or Authority
y �a�sy
Signature Date
I, Ge?Coacle Fhck\)Sc(vA , a Notary Public of the County of kn1 PIKE
State of North Carolina, hereby certify that PRNDLD Q.A1, TN MAN appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this t b►I4 day of 4\Q(Z\L , 20 a4
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Notary
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: 09 13 20_ 'z My commission expires05, 13121),21
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