NCC216444_FRO Submitted_20211119

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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the bla k.)
Part A. �.
1. Project Name � 3 —S �'t �� �C r �" yZ
2. Location of land -disturbing activity: County, [� City or Township
Z l Z ( r )0,90 Longitude J,
Highway/Street
Latitude_ _S r 3J
3. Approximate date land -disturbing activity will commence: '5I"5 k�24;1 4. Purpose of development (residential, commercial, industrial, institutional, etc.): E'_-' u_ IJ
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): '3
6. Amount of fee enclosed: $ D-D - vo _ �. The application fee of $65.00 per ac
up to the next acre) is assessed without a ceiling amount {Example: a 9-acre application fe
7. Has an erosion and sediment control plan been filed? Yes A No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing ac
Name�44-7-7 E-mail Address 312,)4� 7`lc� �
Telephone y iry Z Cell # 1Cy ZLIFax #._ '
9
Landowner(s) of Record (attach accompanied page to list additional owners):
)(J h ,),m 1 �y1 � �� �� s 3 (2- Ll ?8 z� �
Name Telephone
Current Mailing Address Current Street Address
City State Zip City State
10. Deed Book No
Part B.
1
Fax
/�Clu
3
(rounded
is $585).
vity:
r e
!7
Zip
Page No. Provide a copy of the most current deed.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Name E-mail Address
Current Mailing Address Current Street Address
City p (j State I� Zip City State Zip
Telephone 3 ! L r � c� `t �' Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and str�et address
of the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State I Zip
Telephone 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 ndividual
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.
�1410
Type or print name
�0 �nt
Signature
V1 0 /166---
Title or Authority
Date
zZ)
o a Notary Public of the County of
State of North Carolina, hereby certify that P,-NC. I appeared
personally before me this day and being duly sworn acknowledged that the above f rm was
executed by him.
Witness my hand and notarial seal, this day of 0 . , 20 �
Pc,tly C cionlz
!VOTARY PUBLIC Notary
Seal kdoll County, NC
My Commission Bxp;res December17,2021 My commission expires 2 li _) o ,11