NCC220092_FRO Submitted_20220110

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 unavailable, place N/A in the blank.)
Para A. JOEL FAHNLEY PROPERTY (LAKE ADGER)
1. Project Name
2.
3
Location of land -disturbing activity: County POLK
Highway/Street SOUTH COVE ROAD Latitude 35.333344
City or Township MILL SPRING
Approximate date land -disturbing activity will commence: ASAP
Longitude -82.196264
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.59 ACRES
6. Amount of fee enclosed: $ 260 . 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=_ NEnclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name DAVID ODOM E-mail Address [e-mail]
Telephone [phone] cell # 828-249-4355 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
FAHNLEY JOEL ALEXANDER ET UX ,FAHNLEY KIM BRIANT 828-808-6259
Name
263 SYLVAN LANE
Current Mailing Address
MILL SPRING ,NC 28756
City State
10. Deed Book No. 446
Page
Telephone Fax Number
263 SYLVAN LANE
Current Street Address
MILL SPRING ,NC 28756
Zip city
2036
State
Zip
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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
FAHNLEY JOEL ALEXANDER ET UX,FAHNLEY KIM BRIANT [e-mail]
Name
263 SYLVAN LANE
Current Mailing Address
MILL SPRING ,NC 28756
City
State Zip
E-mail Address
263 SYLVAN LANE
Current Street Address
MILL SPRING ,NC 28756
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:
JDr_L Joe.\� ernoC4Pa".e,P..Cnr,r,
Name E-mail Address
26S S �)\VAN LPAyT- ZG S S�OIVA') LA�nnr'
Current Mailing Address Current Street Address
M\A Soft\NCs SIC 2u97SG Snz1NNC 287SG
City State Zip City IState Zip
Telephong 87_b ? 50 (5- Co Z S q Fax Number �f A .
(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 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 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.
FAHNLEY JOEL ALEXANDER ET UX ,FAHNLEY KIM BRIANT OWNER
Type or print name
Title or Authority
I a�
Date
otary Public of the County of:Elnc j' NG",
State of North Carolina, hereby certify that i e rakki I tw appeared
personally before me this day and being duly sworn ackndwledged that the above form was
executed by him.
Witness my hand and notarial seal, this LLday of 5Q. kMbe r , 20_L_
e4 Notary Public ?'2
Seal _ ® Henderson �
My Comm. Exp.
s, 30
V I" I AA -
Notary
My commission expires