NCC191021_ESC Approval Submitted_20190719

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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 L(//�
2. Location of land-disturbin activity: County City or Township iry11
Highway/Street �'fLQ Latitude
Longitude
3. Approximate date land-disturbing activity will commence: ry�``
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): i 4i
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 $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to onteTt should ero$/ion 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
Corr cte ' formation shotald there be any change in the information provided herein.
Type or . rint n97me Title or Authority
g ture r Date
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a Notary Public of the County of %f J- �C
l /
State of North Carolina, hereby certify that F v o Irc�l appeared
personally before me this day and being duly sw rn acknowledged that the above form was
executed by him.
Witness my,ban.d;;and notarial seal, this day of , 20
e0as��•o•..,• y �f
• ° •
NO TA GN
z; R}" e $ Notary
' Auger s
�' °•. �� My commission expires 74,9 a
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