NCC200111_ESC Approval Submitted_20200114

CERTIFICATE OF PLAN APPROVAL
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The posting of this certificate certifies that an erosion and sedimentation control plan has been approved
with performance reservations for this project in accordance with the requirements of the City of Archdale
ACE Integrated Stormwater Management Program and in accordance with the requirements of the North
Carolina Division of Energy, Mineral and Land Resources in accordance with North Carolina General
Statute 113A — 57 (4) and 113A — 54 (d) (4) and North Carolina Administrative Code, Title 15A, Chapter
4B.0107 (c). This certificate must be posted at the primary entrance of the job site before construction
begins and until establishment of permanent groundcover as required by North Carolina Administrative
Code, Title 15A, Chapter 4B. Chapter 4B.0127 (b).
304 Goodman Street — 0.08 ac/SB0.34 ac
COA-2020-016 WS-IV 17-(9)-1 HUC 030300030106 La 35.907661 Lo-79.969338
January 6, 2020
Date of Plan Approval
Project Name and Location
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Archdale
— UNITY • LOYALTY • PROGRESS —
1969- 2019
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D. J. Seneres, PE
City Engineer
Stormwater Program Manager

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 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
2. Location of land -disturbing activity: County ,e- ...t - r .l City or Township. , C 1"fi
Highway/Street! f, /s �1� f-�_.: Latitude 4 7�b Longitude — 79 - 96 / 3 3
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.):;
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): r ' U `i "� '� ' _.- Z--J-
6. Amount of fee enclosed: $ (r` 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 contact should erosion and sediment control issues arise during land -disturbing activity:
Name �� �✓% -L- ? _ rl �. -mail Addre
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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 Title or Authority
Date
I,*, ,� , a Notary Public of the County of 911'1(Ad.
State of North Carolina, hereby certify that �,6'1�2s L .�� 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 6r 9 day of ( L.i+11l:! 20
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--°= Notary
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My commission expires
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