NCC221311_FRO Submitted_20220413

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 NIA in the blank.)
Part A. 900 US HM 17 HOLLY RIDGE
1. Project Name
2. Location of land -disturbing activity: CountygNSLOW City or Township STUMP SOUND
Highway/Street 900 US HVVY 17 N Latitude 036'23. "N Longitude 77* 2g13.2` W
3. Approximate date land -disturbing activity will commence: AS SOON AS POSSI B LE
4. Purpose of development (residential, commercial, industrial, institutional, etc.):MMERCIAL
5. Total acreage disturbed or uncovered (including off -site Morrow and waste areas): .7
6. Amount of fee enclosed. $ 400 . The application tee of $100.00 per acre (roundest
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
7. Has an erosion and sediment control plan been fled? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name CHRISTOPHER BRUCE SNYDER E-mail Address [e-mail]
704-906-6080
Telephone _ _Cell # � Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CHRISTOPHER BRUCE SNYDER 704- 06-6080
Name Telephone Fax Number
236 LOGGERHEAD COURT 236 LOGGERHEAD COURT
Current Mailing Address Current Street Address
WASHINGTON NC 27889 WASHINGTON NC 27889
City
State
10. peed Book No. 5591
Zip City state Zip
Page No_ 560 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 or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
CHRISTOPHER BRUCE SNYDER CSY 110@GMAI OM
Name
E-mail Address
236 LOGGERHEAD COURT
Current Street Address

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:
Dame of Registered Agent E-mail Address
Current Mailing Address
City State Zip
Telephone
Current Street Address
Fax dumber
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.
Type or print name
4� C
Signature
Title or Authority
Date
e"r— , a Notary Public of the County of
State of North Carolina, hereby certify that ar► S4V t�!nvw&c appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by hire.
t-L
Witness my hand and notarial sea), this i r day of _ �y _ , 20 � �