HomeMy WebLinkAboutNCC191730_ESC Approval Submitted_201909066�
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No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this f
and an acceptable erosion and sedimentation control plan have been completed and approved by the L
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.
I Project Name 3,0 cl,
2. Location of land -disturbing activity: CountyY:t�,N,,,�kok City or Township
Highway/Street ;cAl '�r Latitude 516c% Longitud;
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): &o e c-c
75, 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): . .... .....
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? YesC No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name V-C&S-90't E-mail Address +V'tv
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.
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Type or print name
Signature
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Title or Authorit�
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Date
1, T. a Notary Public of the County of
State of North Carolina, hereby certify that I m� appeared
personally before me this day and being duty sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this 20
_k4day of 410JII�_�_
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0 ry ublic My commission expires 09 / '2'-1, 2_02-o
Randolph County, North Carolina