NCC190687_ESC Approval Submitted_20190621

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FINANCIAL RESPONSIBILITY/OWNERSHIP FOR04
SEDINIE1NTATION POLLUTION CONTROL ACT
No person may initiate any Iand-disturbing activity on one or more acres as covered by the Aci 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 Nflk its the blank.)
Part A.
Project Name
Location of land -disturbing activity: County P r,, ,,l (, City or Township .� `,,lr..t,,
Highway/Street-t 01 , t �5,, Latitude Longitude
3. Approximate date land -disturbing activity will commence:��
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
L t r,-
6. Amount of fee enclosed: $ I 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 Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name- l t ', t' -f (' E-mail Address i �_l ,�:�,1, r : �; •,�
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.
Jatob bhoC>
Type or print name
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D�IL�.IVS. �� CbJ1S�(�C6LC��CN
Title or Authority
211 - / '�
Date
a Notary Public of the County of 711, n ()d,-) f ` 4
State of North Carolina, hereby certify that U G Cob -E­ I lrc J
personally before me this day and being duly sworn acknowledged that the above form wads
executed by hire,
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Witness try hand and notarial peal, this l '} day of7-•�ijWI.���,�-1�1 -- -, 20 19
i Mlo'Wy Public No# y
North Cafolina •
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