NCC190592_ESC Approval Submitted_20190612

FINANCIAL RESPONSISILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
71.A AN
No person ma initiate a y ny 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 ion e
2. Location of land -disturbing activity: County Ranrlc)l P h City or Township nrr-hrlzle
Highway/Street 10902 N Main Statitude Longitude.
3. Approximate date land -disturbing activity will commence: 5-22-201 9
4. Purpose of development (residential, commercial, industrial, institutional, etc.): ('ommPrr-i al
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):. 1 / 2 acr
6. Amount of fee enclosed: $ . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Nz ;e Dannv Burton
E-maid:4ddressdburton(aburtonbuildersinc, com
Telephone [phone] Cell# 336-362-5671 Fax# [phone]
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.
&e)Wt4-
Type or print name
4
Signature --
--------------- Date
d Vtlize.v
Title or Authority
$ - z.:,>._iy
------------------------------------- ---
I. �i7eCC' i `aK5 -
a Notary Public of the County ofujrdson
State of North Carolina, hereby certify that
personally before me this day and being duly sworn acknowl dged that the above form was appeared
by him. executed
Witness my \a $G InA llr�q orial seal, thi�day of
!z
�0 J'=
NOTARY N to
SeaOUSLIC _ ry
' O Zvi
My commission expires '-2-0-ao
�!i�SONI coe'��