NCC216916_FRO Submitted_20211214

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 1
unavailable, place N/A in the blank.)
Part A.
1. Project Name ACONY BELL _ PB3 (HENBE--2022-008)
2. Location of land -disturbing activity: County Henderson City or Township Milis River
Highway/Street NC-280 (BOYLSTON EWY)Latitude 35.3296 Longitude-82.6372
3. Approximate date land -disturbing activity will commence: OCTOBER 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):5.0ac (prey. 4.Oac)
$65 ($260 prev. paid,
6. Amount of fee enclosed: $ $325 total) . 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 x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name MARK BROOKS E-mail Address [e-mail]
Telephone [phone] Cell # 828-337-3075 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
ACONY BELL OF WNC LLC 828-337-3075
Name Telephone Fax Number
17 ARLINGTON ST 10517 BOYLSTON HWY (NC-280)
Current Mailing Address Current Street Address
Asheville, NC 28801 MILLS RIVER, NC 28759
City State Zip City State Zip
10, Deed Book No. 3077 Page No. 0556 Provide a copy of the most current deed.
Part B.
1. 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 maybe listed as the financially responsible party.
ACONY BELL OF VINC LLC [e-mail]
Name E-mail Address
17 ARLINGTON ST 10517 BOYLSTON HWY (NC-280)
Current Mailing Address Current Street Address
Asheville, NC 28801 MILLS RIVER, NC 28759
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
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:
14ARK BROOKS
Name of Registered Agent
17 ARLINGTON ST
Current Mailing Address
Asheville, NC 28801
PIBROOKS@BROOKSEA. COM
E-mail Address
17 ARLINGTON ST
Current Street Address
Asheville, riC 28801
City State Zip City State Zip
Telephone [phone] Fax Number 828-337-3075
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
Signature Date
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State of North Carolina, hereby certify that L S appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
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