NCC190655_ESC Approval Submitted_20190619

CERTIFICATE OF PLAN APPROVAL
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The posting of this certificate certifies that an erosion and sedimentation control plan has been
approved for this project by the City of Archdale in accordance with the requirements of the
North Carolina Department of Environment and Natural Resources in accordance with North
Carolina General Statute 113A — 57 (4) and 113A — 54 (d) (4) and North Carolina
Administrative Code, Title 15A, Chapter 413.0107 (c). This certificate must be posted at the
primary entrance of the job site before construction begins and until establishment of
permanent groundcover as required by North Carolina Administrative Code, Title 15A,
Chapter 4B. Chapter 48.0127 (b).
112 Shining Way — 0.21 ac/SB1.18 ac
C®A-2019-0(M Class C 13-2-3 HUC 030401030404 La 35.861199 Lo-79.933024
June 19, 2019
Date of Plan Approval
Project Name and Location
ewn
NCDENR
. J. eneres, PE
City Engineer
Stormwater Program Manager

44
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 Environment and Natural Resources. (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
2. Location of land -disturbing activity: County_ is <9 rid P f `k City or Township
'° L�Highway/Street /% Latitude Longitude -�
Approximate date land -disturbing activity will commence: J t,A e 17. .1 L i`l
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_ �� Z
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 iZ No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Vic_ `�i'r / ��� z e E-mail Address r1l, e; z e J CJ Inc/,
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.
Type or print name Title or Authority TT
Signature Date
�'�.A_...' ~^fibre,"
ftrl a Notary Public of the County ofY'r.,'t;
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State of North Carolina, hereby certify that " 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 �Cf .r,, day of _� i,�.�,�.(� 120
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SUSAN T. SWAIM Voun
Public Notary
Randolph,North Carolina
My commission expires `� -- �(,:: _ 2 0 2 t