NCC220936_FRO Submitted_20220302

No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and on acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Gection, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type orprint and, ifthe question ionot applicable orthe e-mail and/
orfax information unavailable, place NIA inthe b|ank.)
Part A. The Orchards
1 . Project Name
�m�Q� �����|��O�
2. Lnondunof|end'd�turbinQaot��v: Cou "^'' C�yorTnwnahi ' `~ ''' `^
[�e|fa��fre�t ����O��� �D�AM1A�1
Hi�hwmy/Stne Lmtitud =' °=�='^° Longitude -^^°~-°°'"'
3. Approximate m�date land-disturbingactivity
will A/1��M°�1
commence: =''�=�'
���c''���[lf'��|
4. Purponmofdeve�pment�enk1anhe[oommerckd.indua��|'instut�no|,eto)�"~"^^/" Residential
�
5. Total acreage d�turbodoruncovered (including off -site borrow and waste ereme): 1- —--
��0UM
8. Am�nt�f��d��: The application fee of $65.00per acre (rounded
uptothe next acre) inassessed without aceiling amount (Exemp|e:a9'auvaapplication fee ia$585).
7. Has anerosion and sediment control plan been filed? Yes NoEncbXmed.�_____
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Nam ]0hFUafha[l McCall E-mail Address mcoaU@mano|ine-dava|opnnenLuom
��^1-��^1-1��A/L
Telephone '°` '^� '°°` Cell # Fam#
Q. Landowner(s)ofRecord (attach accompanied page tolist additional ownen):
� � �� N�& | | ��
� .~ ~ USA,.���^
Name
Telephone Fax Number
P.O.% �1��
^ ~^^°�� _,^~~,
Current Mailing Address
Current Street Address
Indian Trail, NC 28079
City State Zip
City State Zip
�1�/1� D�DO�
10. Deed Book No "'°-`"- Page No "°""" Provide ocopy ofthe most current deed.
Part 13'
1. Company(ioo) or 5nn(e) 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 isesole proprietorship,
the name of the owner or rnanager may be listed as the financially responsible party.
Carolina Development Services, LLC
'M0cc@||@caro|'0Gk-deVe|000OeOt'CCJ00
Name
E-mail Address
2627 B[eknO 'dge Centre D[.
2627 BrekmOr'dge Centre [l[
Current Mailing Address
Current Street Address
Monroe NC 28079
MQO[Qe 0C 28079
City State Zip
City State Zip
�M^1-7r��-1���
' °-` ' ' -` '"=�
Telephone
Fax Number

2. (a) If the Financially Responsible Party is not a resident of NortV 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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
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.
G. David Cuthb op--, Manager
Type or p ' t na Title or Authority
2cl
ignature Date
S S u -, a Notary Public of the County of Li-V\ U ^
State of North Carolina, hereby certify that G ' `) `8 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
IIiI 1/1fj
0 'd
tD Seal.
(1BOO
day of w t 20 T(
Notary
My commission expires ?' 79— -LO a_.�