NCC241982_FRO Submitted (2)_20240628

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the City of
Greenville, Engineering Division. (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 Di Pk -t;,-1)
2. Location of land-disturbing activity: County P City or Township 0 re,6-7;�.,`I?L
Highway/Street i Latitude Longitude
3. Approximate date land-disturbing activity will commence: '-/1C r /
4. Purpose of development (residential, commercial, industrial, institutional, etc.): -P
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
6. Amount of fee enclosed: $ . The application fee of $100.00 per acre (rounded
`o the tenth of acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed `✓
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name <� L ? ice 1V , E-mail Address J C
Telephone Cell# S`A) 74 ,2/ Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
csmiggisiwk 1) M e„^4 6-1) `>9-,) J 76 : ASS
Name Telephone Fax Number
(al`�
11 , rthvr rit > •, "�
Current Mailing Address � Current Street Address
City State Zip City State Zip
10. Deed Book No. .3% Page No. 9 6.2 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone S y/2- ?i'f,-`. /5,5 Fax Number