NCC190818_ESC Approval Submitted_20190702

FINANCIAL RESPONSIEILITYIOWNERSHIP 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 NIA in the blank,)
Part A.
Project Name
2. Location of land -disturbing activity: Count' L r_
y City or Township /'�
Highway/Street "
r am► sa ��Latitude Longitude_ V � 1/
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): �1-' tI l�t�l I "[�
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): G S �
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 V_�_ No Enclosed_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
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
ignature
i u,e_ �
Title or Authority
Date
a Notary Public of the County of
State of North Carolina, hereby certify that ` - : ,
personally before me this day and being duly sworn acknowledged that the above form was epxecuted
by him.
Witness my hand and notarial seal,
SUSAN T. SWAIM
Notary Putgfo
Randolph Cam, North CardIna
this �:'A of
Y . t A�f , 20
Notary
My commission expires ' - f - - I = C7

CERTIFICATE OF PLAN APPROVAL
CC
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 4B.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 4B.0127 (b).
102 Gracie Court — 0.17 ac/SB0.82 ae
COA-2019-010 DVS -IV 17--9-(1) HUC 030300030106 La 35.922210 Lo-79.954746
June 25, 2019
Date of Plan Approval
Project Name and Location
ern
NCDENR
I}. J. Seneres, PE
City Engineer
Stormwater Program Manager