NCC220930_FRO Submitted_20220301

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hG tiG SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
Re"L s�$uua 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form and an acceptable
erosion and sedimentation control plan has been completed and approved by the Lincoln County Natural Resources Department.
(Please type or print. If the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A tt t!
1. Project Name one jriT Parce.lS.
2. Location of land -disturbing activity: Latitude 35 • S13 Longitude ��' �� � 1(J3t00to
Parcel Identification Number PIN) M Utal h. e Watershed Area 105 V 01
Highway/Street Address Y 1I.( O.S to ©$
3. Approximate date land -disturbing activity will commence: f5-ftF` Fe,63 2—OZZ����
4. Purpose of development (residential, commercial, industrial, institutional, etc:):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)::
C0
6. Amount of fee enclosed: $ 400 It "' . The Standard Permitting application fee of $200.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 9 acres total $1,800), The Express
Permitting application fee is a dual charge. The normal fee of $200.00 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 $3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed V
8, Local appointed person to j �onta/ct should erosion and sediment control issues arise during land -disturbing activity:
NameX
f' l`{� i.,_ 0 7- ", E-mail Address /~�itr''. I . t l�'r t (. "# "r +> ' 4 - t r f� , t/
Telephone 6 I3 (-- 70 —LS-81 Cell # ' Fax #
9. Landowner(s) of Record (attach accompanied page to lists additional owners):)
Na e Telephone Fax Number
l`'N l
Current Mailing Address
V�i � ti-t
City State Zip
Current Street Address
City
State
Zip
10, Deed Book No Mugnel- Page No5F—e QMW most recently filed in Lincoln County Register of Deeds.
L.crt 1 .3121.923 Lo12:3110 o Lod' 3:3bio-Ls8 lot -a. 31A-39S I.V+S`. 311q-"154 U+i0:3131-95
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
Name
Current Mailing Address
City
Telephone Fax Number
Current Street Address
State Zip City State Zip

G SOIL EROSION and SEDIMENTATION CONTROL
fi Lincoln County Natural Resources Department
Rt L 115 Vilest Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
Part B
1. 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):
lLr1 r I' 1. t 1 �I t �1' Name E-mail E-mail Address
3G`, 141 Cry &'1 Z tl
Current Mailing Address Current Street Address
f_t iL X ,
City State Zip City State Zip
Telephone61,
/, 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 State
Telephone
E-mail Address
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 State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
(c) in order to facilitate 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:
Engineering Firm or other consultant E-mail Address
Current Mailing Address City State Zip
Individual contact person (type or print) Telephone Fax Number

cQz SOIL EROSION and SEDIMENTATION CONTROL
g Lincoln County Natural Resources Department
IN 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
RCSOURCCS,
' t � �` Mr. � • � - Alin � � - ,� �y ,.
(d)Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
Name of Person or Firm IName of Person or Firm
fCurrent Mailing Address Current Street Address
City State Zip City State
(� -
At t7 r
Individual contact person (type or print) Individual contact person (type or print)
Telephone 63L l f�'2 _15 W � Telephone
Fax Number
Fax Number
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 by any change in the information provided
herein and any other associated documents. I understand that all documents that are associated with this project and
project number are parts of the complete project document.
Permission to Enter on Land
I certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents to enter on the land in question in connection and/or related to this permit.
Type or print name Title or Authority
ignature Dates
-----------_----------------�-----}-_-------f----------------------------------------------------------------------t---------- -
I, , � f 1 � ' ' f �-t L! S % t ! a Notary Public of the County of b' 1(it 1)"
State of North Carolina, hereby certify that AA6 66 t ' "/h appeared personally before
me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seat, this day of e q' i , 20 '
LRllill)���
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Seal©: pTAR}•
C1 My commission expires 7) h
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