NCC205476_ESC Approval Submitted_20201130

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FINANCIAL RESPONSIBIL1TWOWNIERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT 4
No person !nay 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 thee -mail and/or fax information
unavailable, place fit/A in the blank.)
Part A.
-I. Project Name__ Quaker Field Subdivision
2. Location of sand -disturbing activity: County Randolph City or Township Archdale
Highway/Street_ Robbins Country Rd Latitude 35.877781 Longitude-79.955811
3. Approximate date land -disturbing activity will commence: November 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): Less than 2 ac
6. Amount of fee enclosed: $ 130 . 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 $5851.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John Rosebaum E-mail Address allsquare4u rvahoo.com
Telephone [phone] Cell # 336-800-7422 Fax #
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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T ype'..ar print name Title or Authority
Signature
" C
Date
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Notary Public of the County of
State of North Carolina; hereby certify that __ appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by hire. ,,``\,1�Nq11+MINJI14", �
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\Alitness my han
COMMISSION EXFINES
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Seal
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My conni-nission expires , '
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