NCC220915_FRO Submitted_20220228

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 a -mail and/or fax
information unavailable, place N/A in the blank.)
Part A.
1. Project Name Harshaw Road Grading Plan
2. Location of land -disturbing activity: County Cherokee City or Township Murphy
Highway/Street Latitude . 11 Longitude3�22�5
Harshaw Road 36.06B8
3. Approximate date land -disturbing activity will commence: June 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.86 acres
6. Amount of fee enclosed: $130+a00 " $630 _. The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585),
T 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 Lee McKeon
- E-mail , - E-mail Address [e-mail]
Telephone [phone]
Ceti # Fax #
9. Landowner(s) of Record (attach
accompanied page to list additional owners):
Lee & Kenneth Mckeon
828-360-6440
Name
Telephone Fax Number
465 Harshaw Place
466 Harshaw Place
Current Mailing Address
Current Street Address
Murphy NC
28906 Murphy NC 28906
City State
Zip City State Zip
10. Deed Book No. 1667
Page No. 460 Provide a copy of the most current deed.
Part S.
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.) it the company or firm is a sole
proprietorship, the name of the owner or manager may be fisted as the financially responsible party.
Lee McKeon I,mckeon@,wellswest.com
Name E-mail Address
465 Harshaw Place
Current Mailing Address
485 Harshaw Place
Current Street Address
Murphy NC 28906 Murphy NC 28906
City State Zip City State Zip

Telephone Fax Number
2>3-360-C440 r
2. a If the Financially Responsible- .. -��� () y Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
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
Parry is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City state Zip
Telephone
E-mail Address
Current Street Address
City state Zip
Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
BREC, PA [e-mail]
Engineering Firm or other consultant E-mail Address
Justin Church, PE 336-844-4088 336-609-7726
Individual contact person (type or print) 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.
Lee McKeon
Type or print name
. &A M C, h44�'�
Signature
Owner
Title or Authority
Date
I_YY&gd 1,4 d siDn a Notary Public of the County of C C kcz r
State of North Carolina, hereby certify that �, rJ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by Mm. hr'y
Witness my hand and notarial seal, this 2,3 Pb day of_jLLn — 20 21
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