NCC191456_ESC Approval Submitted_20190828

FINANCIAL RESPONSyBKUTY/OWNERSHIPPORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Actbefore this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land -
Quality SeoUon, 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 inthe b|ank.)
Part A.
1. Project Name
2. LocaUonmf|and-d�turbihgaodvUy Coun | CdycvTo�n��|
Highway/Street 41 Latitude Longitude
3. Approximate date land -disturbing activity will
4' Purpose of development (residential, commercial, industrial, institutional, etc.): :
���
5. Total acreage disturbed oruncovered (indudingof�o|teborrow and waste a/eas)' ' �
G. Amount offee enclosed: The application fee of$G5,OOper acre (rounded
uptVthe next acre) iaassessed amount (Examp|e:eS-acnaapplication fee is$S05).
''/
7. Has onerosion and 'sediment oon�o|plan been �[ed? Yes � No Enclosed
& 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.
Title or Authohty
Type o7rrint na ej,
~
�yJ�t�ryPUbUcofthe County of
|'
appeared
State of North Carolina, hereby certify that
personally before nmethis day and being duly svvun/acknowledged that the above form
byhim.