NCC215892_FRO Submitted_20211022

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APPLICATION FOR PERMIT FOR A n 3/A7 *25605 File k__&35
LAND DISTURBING ACTIVITY G
Under the conditions set forth by XS8 LD Fee .4 Review Fee
The New Hanover County
Soil Erosion and Sedimentation Control Ordinance j25
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Engineering Department 't L
Applicant or Applicant's Agent: Libby Shelton
Mailing Address: 131 Racine Drive, Suite 201 wo : 2_5 R,3 Telephone Number: 843-709-0752 Fax Number:
Wilmington, NC 28403 10 Email Address: [e-mail]
Total Acres of Land Disturbance: 86 Purpose of Development: Residential
Description of Land Disturbance: 258 residential lot subdivision and amenity center as part of Sidbury Farms development
Address of Land Disturbance 6010 & 6220 Sidbury Road
Land owner(s) of record:
Name: John Rudolph, RMP Sidbury Road, LLC
Address: 1401 Central Avenue, Suite 200-D
City/State: Charlotte, NC
Zip Code. 28205-5366
Telephone Number: 704-372-8000
Email: [e-mail] FaxNumber
Latitude: 34.33 (34° 19' 45.876" N) Longitude: -77.115 (77° 51' 2.304" W)
STATEMENT OF FINANCIAL RESPONSIBILITY
Person or firm(s) financially responsible for the
land disturbing activity. If not a North Carolina
resident, you MUST have a N.C. agent. (List Belo
Name: Libby Shelton c
Address: 131 Racine Drive, Suite 20i _
City/State: Wilmington, NC
Zip Code: 28403
Telephone Number: 843-709-0752
Email: [e-mail] FaxNumber:
Location of deed(s) or instrument(s): County: New Hanover _ Book: 15, 20 Page: 89, 27
The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath.
(This form must be signed by the financially responsible person if an individual and by an officer, director, partner, attorney -in -
fact, or other person of authority to execute instruments for the financially responsible person if not an individual.) I agree to
provide corrected information should there be any change in the information provided herein.
Date: _ f a Name . LV. N u _ Title 'SA*
Signature
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I, l hrj a Notary Public of the County of r. u 4 AL;t Vr K State of
North Carolina, hereby certify that c. H o!J appeared personally before me this day and
being duly sworn acknowledged that the above form was executed by him.
Witness my han-1 not seal, this Ti4 day of . Vf— i _ , 20c�a
Notary My commission expires _ (r?S /17l���� _
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Permissio Enter on Lan �,_
I certify that �Z rant and do in fact grant permission to the Erosion CoWA& Inspe l4r„�1[ldai ter on
the land in questiol ii��iection related to this permit application. I (t L
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Application Signature and Date
PLEASE COMPLETE ALL PORTIONS OF APPLI "ATION
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