NCC221502_FRO Submitted (2)_20220419

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FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on '/ acres as covered by the Act before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the Macon County
Planning, Permitting and Development_ Submit this form to: Macon County Planning, Permitting and
Development 1834 Lakeside Dr. Franklin, NC 28734. (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.
1. Project Name Masingill Residence
2. Location of land -disturbing activity: County Macon City or Township Highlands
Highway/Street 477 Walking stick Rd Latitude 35.0368 Longitude 1 -83.1596
3. Approximate date land -disturbing activity will commence: 03/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): I Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.5
6. Amount of fee enclosed: $ 200 The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 1 acre-$100.00).
7. Has an erosion and sediment control plan been filed? Yes NoEnclosed_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jonathan Rackley E-mail Address [e-mail]
Telephoner Cell # 828-508-7937 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Michael Masingili�404-314-9906
Name Telephone Fax Number
143 Wildwood Dr.
Current Mailing Address Current Street Address
Eatonton GA 31024
City State Zip City State Zip
10. Deed Book No H-` 0 Page No. 679 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.
Michael Masingill [e-mail]
Name E-mail Address
143 Wildwood Drive 143 Wildwood Drive
Current Mailing Address Current Street Address
Eatonton GA 31024 Eatonton GA 31024
City State Zip City State Zip
rev 103020