HomeMy WebLinkAboutNCC191420_ESC Approval Submitted_20190821FINANCIAL 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 farm
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 l{'}
2_ Location of land -disturbing activity: County (And ri City or Township � _
Highway/Street ?,7� hl/ � 4�atitude � C 6 Longitude' 4_
3_ Approximate date land -disturbing activity will commence: l' i a C
4. Purpose of development (residential,. commercial, industrial, institutional, etc.): A-9
S. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
F . The application fee of $65.00 per acre (rounded
S. Amount of fee enclosed: $�/ � pP �
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 e No Enclosed
S. 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
Signature
Title or Authority
Date
a Notary Public of the County of�'�t'I 3
�S ' f
State of North Carolina, hereby certify that ;t"i (,{ '- .,r�, r .;24 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 day of ��,f_�[.k����`" , 20P11
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SU!CountY,
�T. 51111A1M � , LRandolph fary PublicM commission ex lies North Carolina y p -