NCC216755_FRO Submitted_20211207

WATAUGA COUNTY Department of Planning & Inspections
126 Poplar Grove Connector Suite 201 • Boone, NC 28607 * Phone:[phone] a Fax:[phone]
GRADING PERMIT
ALL APPLICANTS ARE RESPONSIBLE FOR OBTAINING ANY STATE
OR FEDERAL PERMITS IF APPLICABLE.
DATE:/0/ZZ/ ZO2(
PROPERTY OWNER: Maymead Materials, Inc PHONE: [phone]
ADDRESS: P.O. Box 911 CITY: Mountain City STATE: TN ZIP: 37683
PROPOSED PROJECT LOCATION: NC Highway 421/221
TAX PARCEL #: 2931-64-2067-000
GRADING CONTRACTOR: TBD
LICENSE#:
ADDRESS: PHONE:
PURPOSE OF GRADING: Provide Waste Site ESTIMATED COST: $,S'60/ 000
HYDROSEEDING? X
AREA TO BE GRADED: (approx. acreage) 11.2 acres HANDSEEDING ? X
NUMBER OF FEET OF STREAM(S) IMPACTED? (If applicable): N/A
EXPECTED START DATE: 11 / 1 / 2021 EXPECTED COMPLETION DATE: 11 / 1 / 2022
The undersigned agrees to conform to all applicab aw�he County of Watauga
and the State of North Carolina: d rt er stat that a�so
ements made hereon are true.
APPLICANT SIGNATU �"'� DATE SIGNED /0 ,ZOZ I
PERMIT FEES $
PERMIT DATA REVIEWED BY:
EROSION PLAN REQUIRED?
PLAN REVIEW BY:
PERMIT ISSUED BY:
OFFICIAL USE
_PAID? DATE
YES/NO
DATE:
LICENSED CONTRACTOR REQ?
PLAN APPROVED BY:
DATE ISSUED:
PERMIT VALID UNTIL:

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. (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.
Project Name Deep Gap Waste Area
Location of land -disturbing activity: County Watauga City or Township New River
Highway/Street US Hwy. 421/221 Latitude 36.2307 Longitude-81.5876
Approximate date land -disturbing activity will commence: November 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11.2
6. Amount of fee enclosed: $ 1,800 . The application fee of $150.00 per acre (rounded up to the
next acre) is assessed without a ceiling amount
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kipp Turner E-mail Address kturnerOmaymead.corn
Telephone Cell # 828-320-3336 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Maymead Materials, Inc.
Name
423-727-2000
Telephone
Fax Number
PO Box 911 1995 Roan Creek Rd.
Current Mailing Address Current Street Address
Mountain City TN 37683 Mountain City TN 37683
City State Zip City State Zip
10, Deed Book No. 2106 Page No. 835 Provide a copy of the most current deed.
Part B.
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.
Maymead Materials, Inc.
Name
PO Box 911
Current Mailing Address
kturner(a)maymead.com
E-mail Address
1995 Roan Creek Rd.
Current Street Address
Mountain City TN 37683 Mountain City TN 37683
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address
City State
Telephon
Current Street Address
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
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
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.
Wiley B. Roark
TypeX p ' t name
Signature
President
Title or Authority
/0 / 22 �7.aZ l
Date
Jessicc, Rw� G✓ebb , a Notary Public of the County of Johnson
Tennessee
State of , hereby certify that Wileu 8. 12ocr c 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
TA
TENNE'SSEE
NOTARY
PUBLIC
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'110 U#I 11111\�\
as day of Oc,+vioer 20 a I
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Not ry
My commission expires og�a4�a�