NCC222313_FRO Submitted_20220706

Re5etForm
Print Form':
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on M, acres as covered by the Act before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the Macon County
Planning, Permitting and Development. Submit this form to: Macon County Planning, Permitting and
Development 1834 Lakeside Dr. Franklin, NC 28734. (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 NameCorkill Development
2. Location of land -disturbing activity: County Macon City or Township' Cowee
Highway/Street Leatherman Gap Rd Latitude 35.2746 7 Longitude -83.3896
3. Approximate date land -disturbing activity will commence: 06/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): I Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 2.0
6. Amount of fee enclosed: $ 200 —�. The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 1 acre-$100.00).
7. Has an erosion and sediment control plan been filed? Yes NoEnclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name LC Jones E-mail Address [e-mail]
Telephone [phone] � Cell # 828-332-8511 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Equity Trust Co FBO Patrick W. Corkill 828-200-0161
Name Telephone Fax Number
7495 Floyd Dr. 7495 Floyd Dr.
Current Mailing Address Current Street Address
Pensacola, FL 32526 Pensacola, FL 32526
City State Zip City State Zip
10. Deed Book No V-11 —1 Page No 204 _] Provide a copy of the most current deed
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship, the name of the owner or manager may be listed as the financially responsible party.
Patrick W. Corkill [e-mail]
Name E-mail Address
7495 Floyd Dr.
Current Mailing Address
Pensacola, FL 32526
City State Zip
7495 Floyd Dr.
Current Street Address
Pensacola, FL 32526
City State Zip
rev 103020

Telephone [phone] Fax Number
(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
LC Jones [e-mail]
Name E-mail Address
6456 Sylva Rd
Current Mailing Address
Franklin, NC 28734
City State Zip
Telephoneli 828-332-8511
6456 Sylva Rd
Current Street Address
Franklin, NC 28734
City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City � State Zip City State Zip
Telephone)jI Fax Number
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.
Patrick W. Corkill
Type or print name
Owner
Title or Authority
Date
--------- --=� ---- -- �---�----------------------------
d K o-G ; e— 1- C L a Notary*ubic Qf the County of /►'lam
State of North Carolina, hereby certify that i-appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my haROsa nipprial seal, this F�flday of j y—A 1 � 20 Z2
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