NCC221537_FRO Submitted_20220422

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initlate 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. GRANT HOME
1. Project Name
2. Location of land -disturbing activity: County RUTHERFORD City or Township BOSTIC
Highway/Street 1787 LUCKADOO MTN ROAD Latitude 35.514 Longitude -81.79
3. Approximate date land -disturbing activity will commence: 3/1 /22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.98
6. Amount of fee enclosed: $ 100.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Start Whittington E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
GRANT, GEOFFREY & BARBARA [phone]
Name Telephone Fax Number
39 KEMPTON ROAD
same
Current Mailing Address
Current Street Address
KEMPTON PA 19529
City State
Zip City State Zip
10. Deed Book No, 002047
Page No. 01969 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
SW Associates Inc
[e-mail]
Name
E-mail Address
735 11 th Ave Blvd SE
same
Current Mailing Address
Current Street Address
Hickory NC
28602
City State
Zip City State Zip
Telephone [phone]
Fax Number [phone]

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
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 State
Telephone.
E-mail Address
Current Street Address
Zip City State Zip
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 be any change in the information provided herein.
Stan Whittington
Type dr pint name Is
Signature
Owner/President
Title or Authority
Y C
Date
I, 6104t gj ± KS6, a Notary Public of the County of -BUy^4'
State of North Carolina, hereby certify that skn W wmg appeared
personally before me this day and being duly sworn ackno ledged that the above form was
executed by him.
Witness my hand and notarial seal, this 4Z day of i-i f 20
� •• � Ot
IAOTAR Y ': Q * ry
Seal Z
My commission expires 0 '5 `5
PUBI.\c '
� r
coo
V