NCC220996_FRO Submitted_20220309

° x"CO°a SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
MRU0UKCs is 115 West Main Street, Lincolnton, INC 28092 704-736-85Q1 Fax: [phone]
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
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 NIA in the blank.)
Part A
1. Project Name Lots e SqAjiewood: MorrfsonPQwre1S
2. Location of land -disturbing activity:
Parcel Identification Nu er (PIN)
Highway/Street Address CJCkM
2
3. Approximate date land -disturbing activity will commence:
9 Longitude � SI.2)95 r�
Watershed Area i'10WQr`L�.tCYtQ_�L Sa79Z
2 is $ r795
ASAP 8$18t.
4. Purpose of development (residential, commercial, industrial, institutional, etc.): tS 93CInTI , r+►gr?5�
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2• SS
//�� av
6. Amount of fee enclosed: $ 400 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 In On 41 �
assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eighties be re
acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 ac7 total $3,800.00).GpnV&SIV4.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Local appointed person to co tact should erosion and sediment control issues arise during land -disturbing activity:
Name Lat,'T GfZJ�r f�' E-mail Address
Telephone Cell # �3v Fax #� L0.A-
9. Landowner(s) of Record (attach accompanied page to list additional owners):
_bEELMe LAC.
Name Telephone
1 vA br.
Current Mailing Address
C zglzo
City tale Zip
10. Deed Book No�lu1 Page No.
Current Street Address
Fax Number
State Zip L-O+ Ll
A.
305% --17 2
most recently filed in Lincoln County Register of Deeds. Loi-s 20, 31
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners): S2, 3to,t38
Name
Current Mailing Address
City State Zip
City
3130— 317-
Telephone Fax Number
Current Street Address
City
State
Zip

('RnOUR
D�NCpSOILEROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
,� 115 West Main Street, f_incolnton, NC 28092 704-736-8501 Fax: [phone]
crs
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
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):
Sa..Q, it t c--�f z—i �r �, beta le' . c. �• `Z `+
Name E-mail A dress4 ,
L. fC &At ✓4 s_�,' F-D cam—
Current Mailing Addrbss Current Street Address
t
City State Zip City State Zip
Telephone uy` 3 { 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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

CQG� SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
RG54URC6 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
1
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
Name of Person orArm
rson or Firm
Current Mailing ACurrent Street Address
City State P4?< "contac
State Zip
Individual contact person (t pe r pint) Inds (type or print)
Telephone
Fax Number
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 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 pf na e Title or Aut rity
2
Sign aWre Date
a Notary Public of the County of __ L1411 'd�►�
State of North Carolina, hereby certify that Sro# appeared personally before
me this day and being duly sworn acknowledged that the a ove form was executed by him.
Witness my hand and notarial seal, this day of 20 Z Z
4�
T. Rio4#
ti�'� ... �( ,. N1.o
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AR My commission expires Z
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