NCC221521_FRO Submitted_20220420

APPLICATION FOR PERMIT FOR A
LAND DISTURBING ACTIVITY
Under the conditions set forth by
The New Hanover County
Soil Erosion and Sedimentation Control Ordinance
File #
LD Fee Review Fee
Date Pd Date Pd
Engineering Department
Applicant or Applicant's Agent: —RSC Engineering, Sonya Edens
Mailing Address: _15226 US Hwy 17 Telephone Number: _910-270-9599_Fax Number:
Hampstead, NC 28443
Email Address: [e-mail]
Total Acres of Land Disturbance: 4.9 Purpose of Development: _Residential — Single Family
Description of Land Disturbance: _Clearing for roadway and swales to support residential development_
Address of Land Disturbance _Dorsey Lane, Castle Hayne Latitude:_34.3062 Longitude:_-77.9400_
Land owner(s) of record:
Name: _Cape Fear Habitat for Humanity, Inc
Address: 3310 Fredrickson Road
City/State: Wilmington, NC
Zip Code: _28401
Telephone Number: _910-762-4744
STATEMENT OF FINANCIAL RESPONSIBILITY
Person or firm(s) financially responsible for the land
disturbing activity. If not a North Carolina resident,
you MUST have a N.C. agent. (List Below)
Name: _Cape Fear Habitat for Humanity, Inc.
Address: 3310 Fredrickson Road
City/State: Wilmington, NC
Zip Code: _28401
Telephone Number: _910-762-4744
Email:[e-mail]_FaxNumber Email:_wendi(i,�capefearhabitat.org_FaxNumber:
Location of deed(s) or instrument(s): County: New Hanover Book: _5819_ Page: _2264_
The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath. (This
form must be signed by the financially responsible person if an individual and by an officer, director, partner, attorney-infact, or
other person of authority to execute instruments for the financially responsible person if not an individual.) I agree to provide
corrected information should there be any change in the information provided herein.
Date: (3 o Name _Stephen J. Spain Title _Executive Director
Signature `
I, ��¢. ►4 S1M a Notary Public of the County of k% ct xS 60h onQ Ui State of
North Carolina, hereby certify that 'S+e_Mie v J . s /4 c appeared personally before me this day and being
duly sworn acknowledged that the above form was executed by him.
Witness my hand and notary`01%IV����t�iday of JCuyti c � 20 2-1
Notary My commission expires
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SEAL
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Permission to Enter on La AIC 1 ?��``
I certify that I am authorized to g' "610 hO in fact grant permission to the Erosion Control Inspector and his agents to enter on
the land in gxestion in connection related to this permit application.
ibi
A
Applica igna re and Date
PLEASE COMPLETE ALL PORTIONS OF APPLICATION